Carcinoid tumors are rare neuroendocrine tumors occurring in 2.5 to 5 cases per 100,000 of the population with 50% developing carcinoid syndrome. Perioperative management of carcinoid syndrome poses a challenge to anesthesiologists. Anesthetic considerations include avoiding factors that trigger release of the bioactive mediators such as avoiding hypotension and catecholamine release. The patient in this case report is a 48 year old male with a history of metastatic neuroendocrine tumor, carcinoid heart disease status post TV replacement and PV replacement, and severe carcinoid syndrome on Octreotide, Lanreotide, and Xermelo presenting for repair of femur fracture.

Patient was taken to the operating room and connected to standard ASA monitors. Patient was maintained on the perioperative Octreotide infusion as instructed by the patient's oncologist. Pre-induction arterial line was placed. Patient was given sedation with Versed and Fentanyl in order to tolerate left lateral decubitus positioning on the fractured hip. Sterile technique was performed and intrathecal catheter placed. Patient was then positioned supine. Isobaric bupivacaine 0.5% was dosed in 0.5mL increments until the patient had satisfactory blockade for surgery. Patient was administered Hydrocortisone and Ondansetron prior to incision. Patient was maintained on a low dose propofol infusion throughout surgery.

Patient remained hemodynamically stable in the perioperative period and was able to return to his floor bed. Patient was titrated off the Octreotide infusion on postoperative day 2 per Oncology recommendations and restarted on his home medications.

Depending on the type of procedure, intrathecal catheters can present an alternative option to maintain hemodynamic stability in combination with an Octreotide infusion in patients with severe carcinoid syndrome. The intrathecal catheter allows for slow titration of medication avoiding large hemodynamic swings that may be seen with single shot neuraxial anesthesia. This case highlights the importance of anesthetic planning and multidisciplinary coordination to maintain safe perioperative outcomes.

This study assessed adherence to surgical antibiotic prophylaxis guidelines in nursing home residents undergoing orthopaedic implant surgery under spinal anaesthesia. Following the initial data collection, targeted interventions—such as staff education and clearer guideline dissemination—will be introduced to improve compliance.

Patients residing in nursing homes who underwent emergency hip surgery under spinal anaesthesia at Sligo University Hospital were identified Inclusion Criteria Nursing home residents who underwent emergency hip surgery at SUH between From July 2024 to December 2024 Exclusion Criteria: Patients with a documented allergy to antibiotics Data collection was conducted retrospectively using the patients’ anaesthetic records to determine the prophylactic antibiotics administered at the time of surgery.

None of the patients received appropriate antibiotic prophylaxis based on their MRSA risk status: 7 patients received cefuroxime alone, despite being classified as high-risk for MRSA. 2 patients received both cefuroxime and teicoplanin

Factors such as an aging population and advancements in neuraxial anaesthesia have contributed to an increase in the number of hip replacements among NHR. While improvements in anaesthetic and surgical techniques have reduced overall complication rates, periprosthetic joint infections (PJIs) remain a significant concern. This underscores the critical importance of appropriate antibiotic prophylaxis. This audit identified a substantial gap in adherence to antibiotic prophylaxis guidelines for NHR undergoing emergency hip surgery at SUH. Despite local protocols recommending the use of teicoplanin for patients with known or suspected MRSA colonisation, none of the patients received the appropriate prophylaxis. Potential contributing factors include a lack of awareness of existing guidelines and limited accessibility to clear, up-to-date guidance for clinical staff.

The advent of laparoscopic procedures has revolutionized the medical field by offering several benefits, including smaller incisions, reduced bleeding, minimal surgical surgical and pulmonary complications during and after surgery, and shorter hospital stays which overall results to a reduction of medical cost. GA is the technique usually performed due to the various effects of insufflation on the respiratory and cardiovascular system of the body. This case report aims to discuss the application of the segmental thoracic spinal anesthesia as an alternative.

A 33-year old ASA II was scheduled for laparoscopic cholecystectomy for cholelithiasis. Appropriate landmarks were palpated and confirmed using ultrasound. TSA was done using a quincke G23 spinal needle was inserted via a paramedian approach at the level of T-8-9 with a mixture of Bupivacaine Isobaric 5 mg and bupivacaine heavy 2.5mg with the following adjuvants - Fentanyl 12.5 mcg, ketamine 20 mg and Dexmedetomidine 10 mcg. The patient was slowly placed in a supine position and sensation was assessed using a pinprick test.

A sensory block between the T2-T10 levels was confirmed. Surgery started, Vital signs monitoring showed blood pressure ranges 79-120/48-80 mmHg, with one hypotensive episode during insufflation, managed with Ephedrine 10 mg intravenously; heart rate range of 39 to 90 bpm with 1 episode of bradycardia managed with atropin 0.71 mg intravenously. Patient's vitals were kept within acceptable limits throughout the procedure. Procedure lasted 2 hours and 6 minutes. There is adequate relaxation and exposure, and the surgeon is satisfied with the technique. No adverse effects were recorded preoperatively.

Evidence suggests that spinal anesthesia can be safely used in laparoscopic surgeries with minimal side effects that can be effectively managed using available pharmacological interventions. The success of this procedure using TSA as our technique is indeed a safe and, in some ways has advantages of GA.

A young female patient scheduled for bilateral lung metastatectomy underwent a T7-8 epidural catheterization in the left decubitus position. 10 minutes after injection of a test dose of 3 cc 1.5 % plain lignocaine with 5 ug/cc adrenaline, she complained of heaviness in the right upper limb. She denied having any sensorimotor symptoms elsewhere and had minimal changes in the pulse rate and blood pressure. Examination revealed sensory deficit in right C7-T8 and left T3-T6 dermatomes and grade 3/5 power in the right hand and forearm muscles. The pattern and distribution of the sensorimotor deficits pointed to intrathecal injection with localization of action to the nondependent side. Isobaric intrathecal solutions are known to behave as hypobaric solutions in the CSF and therefore distribute in an antigravity manner. While total spinal block and severe haemodynamic compromise is well described, our patient had lateralization of effects and minimal haemodynamic changes, probably due to the lateral decubitus position given during the procedure. The patient had an uneventful surgery (under general anaesthesia) and postoperative recovery. The catheter was removed at the end of surgery.

Discussion The test dose described above has been questioned in literature as it has been extrapolated from the lumbar epidural test dose. It has been considered excessive in the thoracic segments due to its potential to cause severe harm negating its role as a ‘test dose’. It was fortunate that our patient had a largely unilateral spinal block rather than a high bilateral block. Also the patient’s alertness in reporting mild symptoms was crucial. In conclusion, the case emphasizes the need to meticulously check for effects of the test dose as well as for anaesthesiologistss to consider a smaller test dose for a thoracic epidural.

Deciding on the type of anesthesia in patients with pulmonary hypertension (PH) undergoing noncardiac surgery is not easy. It is burdened with fatal outcome.

A 84-year-old female patient (165 cm, 80 kg) was scheduled for femoral shaft osteosynthesis. Previously, she had a transcatheter aortic valve implanted and was diagnosed with pre- and post-capillary PH. Twelve days before the surgery she suffered anterior myocardial infarction that resulted in implantation of a drug eluting stent and consequential dual anti-aggregation therapy. Nevertheless, she was highly motivated for the operation even though she was informed of the risks with her being an American Society of Anesthesiologists (ASA) score IV patient. Premedication consisted of excluding clopidogrel for 6 days, with acetylsalicylic acid remaining and given to her together with enoxaparine on the day before surgery. With sildenafil three times a day being part of her daily routine, she took a 20 mg tablet on the morning of surgery. An ultrasound guided fascia iliaca block (FIB) was performed (30 ml 0.25% levobupivacaine). After thirty minutes spinal anaesthesia (SA) at L3 - L4 interspace (6.66 mg of 0.5% isobaric levobupivacaine and 33.3 mcg fentanyl) was administered. Patient was sedated using esketamin and fentanyl, with oxygen given via nasal catheter. Multimodal analgesia with paracetamol and ketoprofen was instituted in the operating room.

The patient was hemodynamically stable throughout the surgery as well as later, in surgical intensive care unit. Two hours after the procedure she was able to move both of her legs, with operated leg being slightly numb. She did not report any pain. Due to drop in hemoglobin 2 units of erythrocyte concentrates were administered. The rest of hospitalization was unremarkable and she was discharged on the seventh postoperative day.

SA together with FIB proved as an excellent option for our patient with PH.

Neurological complications following neuraxial anesthesia are rare and can range from minor, self-limiting symptoms to permanent neurological deficits. We present a case of postoperative transient involuntary lower limb movements in a patient with Ehlers-Danlos syndrome (EDS) raising a diagnostic challenge to differentiate between severe complications, spinal myoclonus induced by neuraxial anesthesia and EDS manifestation.

Case presentation: A 46-year-old female known with EDS underwent hysteroscopy under spinal anesthesia with hyperbaric prilocaine 1%. The intraoperative course was uneventful. However, upon regression of the motor block, the patient developed involuntary, rhythmic, moderate frequency and amplitude, non-painful movements of both lower limbs (Figure 1). These resolved spontaneously within two hours without any intervention. Informed consent for publication was obtained.

Discussion: Given the acute onset, exclusion of serious causes such as spinal cord injury or epidural hematoma was prioritized. Following this, the differential diagnosis focused on spinal myoclonus after neuraxial anesthesia (SM-NA), and perioperative dystonia in EDS. With only 23 reported cases, SM-NA is a rare self-limited complication more frequently reported in women. Its proposed mechanism involves local anesthetic concentration gradients within the intrathecal space leading to segmental spinal disinhibition. In patients with EDS, dystonia has been attributed to peripheral injury or psychogenic movement disorder, making it challenging to diagnose and manage.

This case highlights that in patients with EDS, besides SM-NA, dystonia should also be included in the differential diagnoses following spinal anesthesia. Nevertheless, prompt exclusion of critical complications and detailed patient history are essential for appropriate management and reassurance.

Despite adequate graft function, post-kidney transplant patients receiving complex immunosuppressive therapy continue to present significant anesthetic challenges. We aimed to evaluate spinal anesthesia (SA) as a viable alternative to general anesthesia (GA), the most frequently utilized technique, for the brief CAPD catheter removal procedure.

A retrospective analysis was performed on seven patients who underwent CAPD catheter removal at the Department of Urology, University Hospital Centre Zagreb, Croatia, between January 2023 and January 2025. Spinal anesthesia was performed via a median approach at the L4–L5 interspace using a 25G Tuohy needle, with 11.2 mg levobupivacaine, 5 mcg sufentanil, and 240 mg of 40% glucose in a total volume of 3 mL. Motor blockade was assessed using the modified Bromage scale, and surgery was initiated once the sensory block to pinprick reached the Th4 dermatome.

A sensory block reaching the T4 dermatome was achieved, providing an adequate level for the planned procedure. All patients reported comfort throughout the procedure and were able to tolerate the intervention without difficulty. Deep sedation or general anesthesia was not required. Sensory and motor blockade were fully resolved within three hours postoperatively. Subanalysis of seven patients is shown in Table 1..

Although SA is not the first method of choice for CAPD catheter removal, it is a safe and feasible option due to the brief nature of the procedure, particularly for these patients who are at high risk for GA.

We present the case of a patient who developed anaphylaxis during remimazolam sedation under spinal anaesthesia, despite having undergone a same surgery with the same drug and dosage just two weeks prior without complications.

A 65-year-old female underwent right total knee replacement (TKR) under spinal anaesthesia with continuous remimazolam infusion. The procedure was uneventful, and the anaesthesia plan for her left TKR two weeks later followed the same protocol. Spinal anaesthesia was administered. After a second-level check, remimazolam infusion was initiated. However, within 10 minutes, the patient’s blood pressure dropped significantly, and oxygen saturation declined, necessitating an urgent conversion to general anaesthesia. Due to time constraints, the possibility of a high-level block could not be precisely assessed. A bolus dose of remimazolam (10 mg IV) was administered, followed by rocuronium (40 mg IV) for endotracheal intubation. Unexpectedly, the patient experienced cardiac arrest. After approximately 25 minutes of cardiopulmonary resuscitation, return of spontaneous circulation was achieved under ECMO support.

Given the suspicion of anaphylaxis, drug hypersensitivity skin testing was conducted, confirming an allergic reaction to remimazolam. This case highlights the potential for severe hypersensitivity reactions upon subsequent exposure, even in patients who previously tolerated the drug without adverse effects.

In patients undergoing spinal anaesthesia-induced sympathetic blockade, diagnosing and managing drug hypersensitivity can be particularly challenging. Clinicians must remain vigilant for anaphylaxis, as reactions may not manifest during initial exposure but could become life-threatening upon re-exposure.

Awake spine surgery using regional anesthesia has emerged as a viable alternative to general anesthesia, driven by the growing need to manage an increasingly elderly and high-risk surgical population. This approach is associated with reduced perioperative complications, earlier mobilization, and decreased opioid requirements. We aim to demonstrate the feasibility, safety, and clinical benefits of awake spine surgery through the management of a high-risk patient.

We present a case of an 80-year-old male with severe ischemic heart disease (left ventricular ejection fraction 34%), chronic obstructive pulmonary disease, and metastatic pulmonary adenocarcinoma causing sacral spinal cord compression. The patient was scheduled for lesion excision, laminectomy, and decompression under continuous spinal anesthesia. A continuous subarachnoid block was performed using an initial dose of 3 mg levobupivacaine 0.5% combined with 2.5 mcg sufentanil, followed by supplementary doses of 2 + 1 mg levobupivacaine. Light sedation was maintained with target-controlled infusion (TCI) of propofol, and analgesia was complemented with 2 g of metamizole.

The surgery was successfully completed under regional anesthesia without the need for conversion to general anesthesia. Intraoperative hemodynamic parameters remained stable, with no significant hypotensive or hypoxic events. Postoperatively, the patient developed mild, transient respiratory depression, managed conservatively without escalation of care. He achieved early mobilization within 24 hours and was discharged without major complications.

Spinal anesthesia for awake spine surgery provides a safe and effective anesthetic alternative for high-risk patients who are poor candidates for general anesthesia. This case highlights the potential of awake spine surgery to enable successful surgical intervention while minimizing perioperative risks in fragile populations.

Erector spinae blocks are well-established as a regional analgesic technique for traumatic rib fractures. However, they are less commonly used to manage pain from other traumatic injuries, such as muscle spasm associated with vertebral fractures – a cause of significant morbidity and prolonged hospital admissions.

We reviewed the case of a 45-year-old male, who presented to hospital after falling into a concrete hole, complaining of right-sided chest and lower back pain. CT imaging showed right-sided fractures of the ninth and tenth ribs anteriorly, and the eleventh rib posteriorly; and a right-sided L1 transverse process fracture. A unilateral serratus anterior plane block (SAP) was performed, with incomplete improvement of pain. He subsequently underwent a unilateral erector spinae plane (ESP) block.

The SAP block resulted in improvement of the patient’s chest, but not of his back pain. The subsequent ESP block was effective in reducing both the patient’s chest pain as well as his residual, episodic lumbar back pain. Given the underlying injuries and characteristics of the pain, psoas muscle spasm may have been the cause of the latter pain.

The use of the ESP blocks could be expanded to include psoas muscle spasm in the context of traumatic spinal fractures. It may also be a superior single technique covering both rib fracture pain and spasmodic muscle pain associated with spinal fractures, compared to SAP and potentially other combination blocks. The use of ESP here may have multiple benefits, including minimising systemic analgesic requirements, reducing morbidity and expediting hospital discharge.

continuous spinal anesthesia (CSA) involves inserting a catheter into the subarachnoid space. his main advantage is the titration of the induction dose, which allows for control over the extent of blockade and its onset speed, thereby minimizing side effects, particularly hemodynamic ones. It is primarily indicated in elderly patients. Despite its advantages, CSA remains underused.

We report a series of 5 cases demonstrating the value of CSA for lower limb trauma surgery in elderly patients.

Case 1: 80-year-old female patient , with a history of heart disease, admitted for a left femoral shaft fracture. Chest X-ray showed cardiomegaly. ECG: ACFA. echocardiography: LV dysfunction, EF: 40%. operated under CSA: - 1st injection of 05 mg of bupivacaine + 10 µg of fentanyl; 2nd injection: after one hour : 2.5 mg of bupivacaine After closure, injection of 100 µg of morphine and removal of the intrathecal catheter on the table; - The procedure lasted 1 hour 30 minutes during which the heart rate was unstable ; but no hypotension. Case 2: Patient BF, 86 years old, was admitted for a complex subtrochanteric diaphyseal fracture of her right femur. She has a history of: HBP + diabetes + COPD -1st injection: 2.5 mg bupivacaine + 5 ug fentanyl) 2nd injection: after 30 min: 2.5 mg bupivacaine + 5 ug fentanyl Patient had a hypo BP 06/04 regulated by filling 3rd injection 1 h 40 min: 2.5 mg bupivacaine + 5 ug fentanyl the trird, the forth an the the fifth patients were aged between 80 and 90 with a history of ischemic heart disease, hypertension, diabetes mellitus they were admited for hip fractures and were operated under CSA successfully.

CSA is a useful technique in high-risk patients (elderly patients with comorbidities). Its advantages are numerous: ease, and reliability.

This study aims to deeply explore the interactions between anesthetic drugs and assess strategies for their prevention and management to enhance surgical safety and patient outcomes.

This prospective study involved 200 patients undergoing abdominal surgery requiring general anesthesia. Patients were divided into two groups: the experimental group (100 patients) received a combination of propofol and fentanyl; the control group (100 patients) received a combination of propofol and rocuronium.

Compared to the control group, the experimental group showed a significantly shorter average postoperative recovery time: 7 days (SD = 1.3 days) versus 10 days (SD = 1.8 days), P<0.001. The complication rate was lower in the experimental group at 12% (12/100) compared to 26% (26/100) in the control group, P<0.01. The incidence of severe cardiovascular events was also significantly lower in the experimental group at 3% (3/100) versus 13% (13/100) in the control group, P<0.05. Additionally, patient satisfaction scores were higher in the experimental group at 4.5 (out of 5) compared to 3.9 in the control group, P<0.001. Serum biochemical markers showed that the serum albumin levels on the third postoperative day were significantly higher in the experimental group at 35 g/L compared to 30 g/L in the control group, P<0.05.

This study confirms that scientific management of drug interactions during anesthesia can significantly improve surgical safety, accelerate postoperative recovery, and enhance patient satisfaction.

Epidural analgesia (EA) is commonly used in major surgeries; however, placement of dual epidural analgesia (DEA) catheters remains rare. In selected cases, DEA may provide broader segmental coverage and opioid-sparing benefits despite added complexity.

A 64-year-old male (65 kg) underwent thoracolaparotomy with esophageal and gastric cardia resection and gastroplasty for gastroesophageal junction cancer in January 2025. Postoperatively, complete anastomotic dehiscence developed, requiring esophageal stump drainage and VAC system application. Three months later, esophageal reconstruction with colonic interposition was planned. Anticipating thoracotomy and laparotomy, DEA catheters (B.Braun Perifix®, Germany) were placed at Th5/6 and Th11/12 (6 cm depth) for opioid-sparing anesthesia and analgesia. Dermatomal coverage was Th3–8 and Th9–L2. Bupivacaine (Bupivacaine-Grindeks spinal, Grindex, Latvia) 0.25% 5 ml was administered every 90 minutes via both catheters, starting with Th11/12 and then Th5/6. Multimodal IV analgesia included paracetamol (Supofen® 10 mg/ml, Laboratórios Basi - Indústria Farmacêutica S.A., Portugal), metamizole (Metamizole Sodium-Kalceks 500 mg/ml, Kalcex, Latvia), ketorolac (Ketanov 30 mg/ml, Sun Pharmaceutical Industries Europe B.V., Netherlands), and dexamethasone (Dexamethasone Kalceks 4 mg/ml, Kalcex, Latvia). During the 530-minute surgery, the patient received 0.2 mg fentanyl (Fentanyl citrate-Kalceks 0.05 mg/ml, Kalcex, Latvia) and a low dose of noradrenaline (Norepinephrine Kabi 1 mg/ml, Fresenius Kabi, Poland). Postoperatively, a continuous epidural infusion of 0.125% bupivacaine (3 ml/h) was maintained via both catheters as part of multimodal analgesia. Pain scores were NRS 0–3 at rest and 3–6 with movement. Epidural morphine was used when NRS >5. No IV opioids were needed. DEA catheters were removed on POD14. No complications related to DEA were observed.

DEA enabled effective segmental coverage and reduced opioid requirements. The total bupivacaine dosage remained within the established safety thresholds, and no complications were observed.

DEA proved to be a safe and effective opioid-sparing strategy in extensive thoracoabdominal surgery, particularly when single-catheter EA may be insufficient.

Post-dural puncture headache (PDPH) is a common complication of neuraxial techniques. Despite rare, progression to cerebral venous thrombosis (CVT) may occur. Risk factors such as thrombophilia and hypercoagulability increase vulnerability. We present a case of PDPH complicated by CVT in a high-risk obstetric patient.

32-year-old primigravida at term, ASA III, with class III obesity, prior pulmonary embolism, and heterozygosity for the prothrombin G20210A mutation requiring labor analgesia. Combined spinal-epidural was performed with a 27G Whitacre needle at L3-L4, followed by successful epidural catheter placement. The patient developed a positional occipital headache radiating to the posterior neck, consistent with PDPH. Conservative management achieved transient clinical improvement. Nine days later, she returned to the emergency department with persistent non-positional headache. Diagnostic imaging revealed CVT of the superior sagittal and lateral sinuses. Neurology consultation confirmed the diagnosis, supported by elevated D-dimers, venous CT, and brain MRI findings. An epidural blood patch and therapeutic anticoagulation with enoxaparin were instituted.

Gradual clinical improvement and favorable radiological evolution were observed during follow-up.

Persistent or atypical headaches after neuraxial anesthesia should instigate prompt re-evaluation and neuroimaging. Recognizing predisposing factors and maintaining a high index of suspicion improve early diagnosis of potential complications. Vigilance, early recognition, and treatment are essential to optimize outcomes and prevent serious morbidity.

Supraclavicular brachial plexus blocks are commonly used for upper limb surgeries but carry the risk of phrenic block due to cephalad spread of local anesthetics, leading to diaphragmatic paresis and respiratory depression. Doxapram, a respiratory stimulant, is traditionally used for opioid-induced respiratory depression, but its role in reversing phrenic nerve-related respiratory compromise remains underrecognized. We present a case where doxapram successfully reversed respiratory depression following a supraclavicular block.

A 68-year-old male underwent elective thumb surgery under general anesthesia with a supraclavicular brachial plexus block using levobupivacaine 0.5% (20 milliliters) under ultrasound guidance. Postoperatively, he exhibited delayed emergence, slow respiratory rate, reduced tidal volume, mild hypoxia, and no signs of opioid overdose. Phrenic nerve involvement was suspected due to diaphragmatic paresis. Doxapram (1 milligram per kilogram intravenously) was administered, resulting in rapid improvement in respiratory effort, rate, and oxygen saturation. The patient recovered fully without invasive support.

Phrenic nerve block occurs in 50-60% of supraclavicular blocks due to local anesthetic spread. While often subclinical, it can cause significant respiratory compromise in patients with limited reserve or residual anesthesia. Doxapram, acting on carotid chemoreceptors and central respiratory centers, effectively reversed respiratory depression in this case. Clinicians should consider phrenic nerve paresis in postoperative respiratory depression and use ultrasound-guided techniques to minimize risks.

This case highlights the importance of recognizing phrenic nerve involvement as a complication of supraclavicular blocks. Doxapram can effectively reverse respiratory depression in such scenarios, avoiding invasive support. Careful patient selection and ultrasound guidance are essential to minimize risks and improve outcomes.

Cerebellar Ataxia, Neuropathy, and Vestibular Areflexia Syndrome (CANVAS) is a rare, neurodegenerative disorder characterized by a triad of cerebellar ataxia, sensory neuronopathy, and bilateral vestibular areflexia. Patients often present with progressive gait instability, chronic cough, and autonomic dysfunction.These multisystemic features pose significant challenges in anaesthetic management. From an airway management perspective, patient are at increased risk for aspiration and may be predisposed to central respiratory failure. General anaesthesia poses more risks due to risk of intraoperative hypotension and labile haemodynamic response to fluid shifts.

We report the case of a 76-year-old ASA III woman with an 8-year history of CANVAS who sustained an intracapsular femoral neck fracture following a fall. The patient maintained independent ambulation; however, she presented to the emergency department on multiple occasions due to recurrent falls. There was no history of neuropathy or orthostatic hypotension. Spinal anaesthesia was decided for total hip replacement surgery. Intraoperative management included vigilant non-invasive haemodynamic monitoring to address potential autonomic instability.

Spinal Anaesthesia with 8,5 mg levobupivacaine was successfully administered without intraoperative complications. The patient remained hemodynamically stable. Postoperatively, there were no new neurological deficits, and recovery was uneventful.

This case underscores the importance of individualized anaesthetic planning in patients with CANVAS, considering their neurological and autonomic features. Regional anaesthesia, such as spinal anaesthesia, may offer a safer alternative to general anaesthesia, minimizing risks associated with airway management and possible haemodynamic instability. Recognizing the specific challenges posed by CANVAS is crucial to optimizing perioperative care and outcomes.

A 75-year-old female patient with a history of arterial hypertension, managed with ACE inhibitors, underwent posterior thoracic and lumbar spinal fusion (T11-L5) for lumbar spinal stenosis (L1-L4). General anesthesia was induced with propofol 1%, rocuronium, and fentanyl, while maintenance was achieved with sevoflurane and remifentanil, guided by bispectral index monitoring to maintain an appropriate anesthetic depth. The patient remained hemodynamically stable throughout the 3-hour operation.

Before emergence from general anesthesia and extubation, a bilateral ultrasound-guided Erector Spinae Plane (ESP) Block was performed at T8 level with the patient in prone position. A single shot of 20 ml ropivacaine 0.375 % and 50 mcg clonidine was implemented on each side. Afterwards, the patient was transferred to the postanesthetic care unit and was discharged 60 minutes later, as her cardiopulmonary status was stable, accompanied by a low pain score (VAS=2/10) postoperatively.

Around 80 minutes after the patient's admission to the Orthopedic Department, significant hypotension was observed, with a systolic blood pressure of 68 mmHg. Physical examination revealed no sensory, motor, or reflex abnormalities in the lower extremities, nor any other signs of local anesthetic toxicity. Laboratory tests and imaging studies were also within normal range. Suspecting ESP block-induced hypotension, continuous hemodynamic monitoring was initiated, along with the administration of 1000 ml Ringer’s lactate solution containing 12 mg of noradrenaline, in order to maintain systolic blood pressure above 110 mmHg. Subsequently, the infusion rate was gradually reduced, and after 48 hours the patient was stabilized hemodynamically, requiring no analgesic regimen.

ESP block-induced hypotension was attributed to the spread of local anesthetic into the paravertebral and epidural space, along with the administration of clonidine and high dose of local anesthetic. Hence, we advocate the infusion of dilute local anesthetic solutions and advise against the use of clonidine in elderly patients receiving antihypertensive therapy.

Myotonic dystrophy type 2 (DM2) is a multisystemic neuromuscular disorder with implications for anesthetic management, particularly due to risks associated with general anesthesia such as respiratory depression, cardiac conduction defects, and sensitivity to muscle relaxants. Regional anesthetic techniques, such as regional anesthesia, are often considered safer in these patients. This report aims to illustrate the clinical decision-making process leading to the successful use of spinal anesthesia in a DM2 patient undergoing vaginal hysterectomy for uterine prolapse.

A 68-year-old female with diagnosed DM2 and symptomatic grade 3 uterine prolapse was scheduled for elective vaginal hysterectomy. Preoperative evaluation showed mild proximal muscle weakness, preserved pulmonary function, and no cardiac conduction abnormalities. Considering her neuromuscular condition and the regional nature of the surgical field, spinal anesthesia was chosen to minimize systemic risks. A single-shot spinal block was performed at L3–L4 using 3 mL of 0.75% hyperbaric ropivacaine with 20 mcg fentanyl.

The block achieved a T6 sensory level with adequate motor blockade within 5 minutes. The procedure l was completed without hemodynamic instability or need for sedation. The patient remained comfortable and responsive throughout. Postoperatively, no respiratory complications, prolonged motor block, or myotonia exacerbation occurred. The patient mobilized on postoperative day 1 and was discharged home on day 3 without adverse events.

This case highlights the value of individualized anesthetic planning in patients with DM2. Spinal anesthesia can be a safe and effective choice for pelvic surgery, avoiding the potential complications of general anesthesia. Careful preoperative assessment and vigilant intraoperative monitoring are essential for optimal outcomes.

General Anaesthesia provided for thoracic and upper abdominal surgeries poses high risk in patients with severe respiratory limitations. Thoracic segmental spinal anaesthesia provides an excellent alternative in these patients preserving lung function. This unorthodox technique has been of limited use in the past century with fear of injury to spinal cord and hemodynamic instability. Here, we represent 3 cases of breast excision and reconstruction surgeries successfully done with Thoracic segmental spinal anaesthesia, in patients with multiple comorbidities and severe lung disease, associated with higher risks from GA.

Pre-op assessment of these high risk patients, consent obtained after explaining risks and complications. Thoracic spinal done at T6-T7 interspace, with patient in sitting position. Done with 25-G pencil point needle i midline with necessary angulation. 1.5ml of isobaric bupivacaine with 25mcg of fentanyl was given. Patients were made to lie down supine after the spinal. Sensory loss to cold was present from T3 to T11. Surgery duration was 80-100 minutes. Patients were comfortable throughout the surgery.

Minimal hemodynamic instability after the spinal managed with boluses of metarminol. No respiratory or breathing issues intra-op and post-op. Adequate surgical anaesthesia and pain relief provided by the spinal. No residual numbness or post-op complications. Patients were discharged the following day. A backup plan of GA was in place.

Thoracic segmental spinal anaesthesia has been associated with fewer hemodynamic alterations compared to traditional spinal and has multiple advantages over GA. It still requires a skillful and experienced anaesthesiologist to be performed appropriately. Use of ultrasound in identifying the space has resulted in higher success and is being increasingly used for thoracic, upper abdominal, breast and thoracscopic surgeries. Despite the absence of larger trials, multiple case reports and cohort studies have deemed it to be a safe and feasible alternative to general anaesthesia.

Continuous spinal anaesthesia (CSA) offers a valuable alternative for high-risk patients undergoing major lower limb surgery. In elderly patients with significant cardiovascular comorbidities, conventional neuraxial blocks carry a high risk of hemodynamic instability. CSA offers a valuable alternative by allowing precise dose adjustment. Reducing sympathetic blockage and minimizing hypotension events. This case illustrates the use of ultra-low dose CSA in an ASA IV patient with multiple cardiopulmonary comorbidities undergoing osteosynthesis for a periprosthetic femoral shaft fracture.

An 86-year-old woman with severe valvular heart disease, pulmonary hypertension, and ischemic cardiomyopathy was scheduled for osteosynthesis of a periprosthetic femoral fracture. A suprainguinal fascia iliaca block was performed preoperatively. CSA was initiated via a 20G intrathecal catheter at L3-L4. An initial intrathecal injection of 1.5 mg isobaric bupivacaine with 5 mcg fentanyl was administered, followed by two further boluses of the same dosage at one-hour intervals (total bupivacaine dose: 4.5 mg, total surgical time 202 minutes). Sensory level was evaluated using both temperature discrimination and pinprick test. Hemodynamics were continuously monitored via radial arterial line and Vigileo® system.

CSA provided satisfactory surgical conditions. Hemodynamic parameters remained stable throughout. Estimated blood loss was 350 mL; no transfusions were required intraoperatively. No adverse events noted during postoperative recovery.

CSA using ultra-low dose bupivacaine appears to be a safe and effective option for high-risk elderly patients. Compared to traditional spinal approaches, this strategy enabled precise adjustment of local anesthetic dosing, reducing hypotensive events during prolonged surgical procedures. The use of complementary regional blocks enables lower intrathecal requirement.

Spinal anaesthesia (SA) is an effective anaesthetic choice for perineal surgeries, which is typically performed with the patient seated or in lateral decubitus. For anorectal surgeries, patients need to be repositioned after SA, which can be technically challenging, lead to unpredictable spread of the local anaesthetic, and time-consuming. Therefore, performing SA with the patient already in prone position may be advantageous.

We present a case series of six patients who underwent stapled hemorrhoidopexy under SA already performed in prone position. Following preoperative evaluation, the patients positioned themselves in a comfortable prone position with rolls under the pelvis, chest and abdomen to facilitate lumbar spine flexion. After light sedation, SA was performed with a 27G Sprotte needle in L4-L5 or L5-S1 interspace. Gentle aspiration was usually needed to ensure reflux of cerebrospinal fluid. Levobupivacaine 6,5-7,5mg and Sufentanyl 2mcg were administered.

SA was performed without any complications in all the patients, requiring a maximum of two attempts. After evaluating the effectiveness of the saddle block, the surgery took around 30-45 minutes. Patients remained comfortable and hemodynamically stable. Intravenous Acetaminophen 1g and Ketorolac 30mg were administered for analgesia. All cases were performed as outpatient procedures with discharge under 24 hours.

SA in the prone position remains an underutilized technique. This approach could offer optimal surgical exposure, while eliminating the need for additional mobilization, reducing haemodynamic and respiratory instability. The use of levobupivacaine allowed for reduced cephalad spread, lowering the risk of high SA compared to hyperbaric solutions.

In this review, our clinical experience with neuraxial blockade by using a height adjusted dose of 0.5% isobaric bupivacaine on 1000 ASA physical status I–IV patients undergoing lower limb orthopedic surgery was evaluated. The aim was to summarize anesthetic and hemodynamic effect.

In recent years height adjusted doses of 0.5% isobaric bupivacaine were used for intrathecal administration prior to lower limb orthopedic procedures shorter than 120 minutes. All patients were older than 18 and with ASA physical status I–IV. In Table 1 are listed the used doses. In each height group, the lowest dose of the corresponding bupivacaine dosing interval was given to patients over 65 years, patients with ASA physical status III or IV and for knee surgery, while for hip and femur surgery the highest dose of the corresponding bupivacaine dosing interval was administered.

In most cases the height adjusted dose of isobaric bupivacaine provided an adequate level of anesthesia to safely perform the lower limb orthopedic surgery. Moreover, patients were hemodynamically stable, the incidence of hypotension and bradycardia were very low (<2%). In 1–2% of cases the protocol was changed to general anesthesia, because the level of anesthesia was insufficient or became inadequate during the procedure.

The intrathecally administered height adjusted dose of 0.5% isobaric bupivacaine is associated with adequate level of anesthesia to safely perform the lower limb orthopedic surgery. It provides hemodynamic stability, which is especially significant for elderly and polymorbid patients. The incidence of adverse effects are relatively low and rarely require pharmacological intervention.

Epidural analgesia is an effective method for postoperative pain management. Nevertheless, it involves risks that require multidisciplinary awareness and careful patient monitoring. This audit aimed to evaluate whether postoperative epidural care at our District General Hospital adhered to national standards (Faculty of Pain Medicine 2020, RCoA NAP3 2009). A baseline questionnaire was distributed to 55 nurses across ITU, surgical wards, and recovery areas. Findings revealed that motor and sensory block was monitored in only 30% and 32% of cases, respectively. Additionally, 43% of nurses were unfamiliar with the Bromage scale, and 40% were unaware of the dermatome chart for sensory block assessment. This project aimed to improve compliance with national guidelines, increase staff awareness of escalation pathways and enhance monitoring of epidural blocks.

In partnership with the Acute Pain Team of our hospital, we developed training videos covering motor and sensory block assessment. We transitioned documentation from paper to an electronic format to streamline monitoring and escalation processes. The pain team conducted in-person teaching sessions, which were complemented by the introduction of a laminated reference guide. This guide included a clear escalation protocol, QR codes linking to our training videos, and a copy of visual aids including the Bromage and Dermatomal charts. These guides were attached to all epidural pumps throughout the hospital.

Following the implementation of these measures, a follow-up survey (n=25) demonstrated that 92% of the nurses monitored and documented both sensory and motor blocks. In addition, familiarity with the Bromage scale increased to 92% and 100% found the laminated guide helpful.

Supporting the existing teaching programme with a visual reference tool led to improved compliance with monitoring standards and enhanced staff knowledge in monitoring patients with epidurals.

Alkaptonuria (AKU), otherwise known as 'black bone disease', is a rare autosomal recessive metabolic disorder resulting in the accumulation of homogentisic acid in connective tissues. Consequently, valvular abnormalities and degeneration of large weight-baring joints such as the hips, knees and spine are seen. There are very few case-reports available in the literature regarding spinal anaesthesia in this group, particularly in the context of also having undergone spinal instrumentation surgery.

We present the case of a 71-year-old lady who had an elective total hip replacement under spinal anaesthesia despite previous extensive spinal instrumentation (T10-S1) and alkaptonuria. Pre-procedural ultrasound resulted in the accurate identification of an inter-spinous space at L1/L2, first pass injection and normal spread of local anaesthetic. Ultrasound avoided multiple unsuccessful attempts at lower inaccessible levels due to scar tissue and degenerative changes.

Successful ultrasound-guided single attempt spinal anaesthesia for a hip replacement surgery for a patient with alkaptonuria who also had a spinal fusion surgery (T10-S1)

In our experience, alkaptonuria and previous posterior spinal instrumentation do not preclude successful spinal anaesthesia despite perceived difficulties. Careful review of old op-notes and radiological imaging is important in planning for neuraxial anaesthesia. More formal training in spinal ultrasound techniques for anaesthetists will likely increase the number of patients who could benefit from spinal anaesthesia following spinal instrumentation or other pre-existing spinal pathology.

Spinal anesthesia is the most widely used and effective anesthesia technique for total hip arthroplasty (THA). Local anesthetic agents can be combined with adjuvants to improve analgesic quality and duration. We hypothesized that intrathecal nalbuphine, added to levobupivacaine, would enhance intraoperative and postoperative analgesia.

After informed consent, 60 patients, aged 18–80 years, scheduled for THA, were randomized into two groups. Group N (n=30) received 3,2 mL of 0.5% levobupivacaine with 0.4 mg nalbuphine intrathecally, while Group L (n=30) received plain 3.2 mL levobupivacaine 0.5%. Exclusion criteria included ASA score > III, BMI > 40, severe psychiatric or cognitive disorders, and allergies to study drugs. The anesthesia team was the same throughout the study, and both patients and evaluators were blinded to group allocation. All patients received 1g paracetamol intraoperatively, continued every 6 hours postoperatively, and a pericapsular nerve group (PENG) block. The primary outcome was acute postoperative pain, assessed by total morphine use within the first 24 hours. Morphine was administered using the MicrelRythmicEvolution PCA pump, and MicrelCare software.

Morphine consumption at 6, 12 and 24 hours was significantly higher in group L (p<0.001). At all time points, the NRS score at rest and at motion was significantly greater in group L (p<0.001). The duration of sensory and motor blockade were significantly higher in the group N (p<0.001). The incidence of hypotension was lower in group N.

Nalbuphine as an adjuvant in spinal anesthesia seems to be safe and effective, reducing postoperative pain and opioid consumption in patients undergoing THA.

Eye surgery is increasingly taking place without anaesthesiologists. Providing safe and cost-effective analgesia, avoiding the risks of traditional sharp-needle blocks is important. This study explores a safe tangential sharp-needle approach for STB, screening for complications and inadequate analgesia through VAS/PROM screening

In 2023, a representative demographic cohort (>18 y) of consenting ASA 1-2 patients (n=907) (median-age 75.5 y) scheduled for anterior chamber eye surgery (refractive, glaucoma and iris surgery) received STB-injection of 1-1.5 ml ropivacaine 2% containing 50 μg dexmedetomidine. STB injected at 8 mm lateral limbus, lateral M rectus inf. insertion (see illustration)

- STB-onset averaged 4 min, -STB-duration > 3 h, - small sub-conjunctival hemorrhage 42%, - conjunctival chemosis 19.4% -18 % of the patients demanded additional analgesia iv (2 /kg fentanyl + 1mg midazolam), reporting VAS scores >/= 3 during surgery

Anterior sharp-needle STB is a valid alternative to blunt-cannula post-aequator STB or epi-caruncular sharp-needle STB in anterior segment eye surgery. 82% of the 907 patients were able to undergo interventions on lens, capsula, cornea, iris and trabeculae without additional systemic analgesia. No grave sharp-needle complications (bulbar perforation, intraorbital bleeding, brainstem anaesthesia, strabism) occurred due to the needle-trajectory running parallel to the scleral surface. Conjunctival hemorrhage and negligible chemosis were comparable to other STB-techniques.

Continuous spinal anesthesia (CSA) offers an alternative to single-shot spinal anesthesia in frail, elderly patients undergoing prolonged lower extremity surgery. Its ability to fractionate intrathecal local anesthetic dosing allows for a gradual onset of sympathetic blockade, mitigating hemodynamic instability compared to single-dose techniques. Point-of-care ultrasound (POCUS) is an effective tool for perioperative assessment in high-risk patients.

Case 1:An 84-year-old ASA III male with ischemic heart disease, atrial fibrillation, and pulmonary hypertension was scheduled for femoral nail replacement. Preoperative POCUS revealed severe pulmonary hypertension, an atrial septal defect, and venous congestion (VExUS grade 2). CSA was performed using a 20G catheter with incremental dosing of hyperbaric bupivacaine (total 12.5 mg). Hemodynamics remained stable without vasopressors. Postoperatively, the patient developed transient atrial tachyarrhythmia managed with volume replacement and antiarrhythmics. Case 2: An 80-year-old ASA IV female with COPD, heart failure, and chronic prosthetic joint infection underwent knee prosthesis explantation. Baseline POCUS showed chronic cor pulmonale, moderate biventricular dysfunction, and VExUS grade 1. CSA with isobaric bupivacaine (total 10 mg) and sedation was used, supported by high-flow nasal cannula. Intraoperative course was stable, recovery uneventful.

CSA enables controlled LA administration with minimal hemodynamic impact in high-risk patients. The incidence of post-dural puncture headache with microcatheters is 1.0-6.5% and infection and hematoma is similar to other neuroaxial techniques. POCUS aids in identifying cardiovascular compromise and guiding management. Its integration enhances perioperative safety.

CSA, in combination with POCUS, is a safe and effective technique in high-risk geriatric patients undergoing prolonged lower limb surgery.

Dreaming under general anaesthesia has incidence rates ranging from 17.5% to 57% depending on timing of assessment and anaesthetic agents used. Previous studies suggest that dreams are typically pleasant and occur during lighter stages of anaesthesia, particularly near emergence. However, the relationship between the type of anaesthesia and dream incidence remains underexplored. Hypothesis: Patients receiving combined general anaesthesia (multimodal GA+regional/local anaesthesia) are more likely to experience and recall pleasant dreams compared to those MMGA without RA.

In this retrospective analysis, 44 patients undergoing surgery under regional or general anaesthesia were assessed postoperatively for the occurrence of dreams. Dream presence, age, opioid use, and anaesthetic technique were recorded. Patients were stratified based on dream recall (dream vs. no dream), and group differences were evaluated using descriptive statistics and chi-squared tests.

Dreams were reported by 23/44 patients (52%). The median age of dreamers was 54 years (IQR 40–68), compared to 62 years (IQR 39–69.5) in non-dreamers. Most patients (31/44, 70%) received combined anaesthesia (multimodal GA+regional/local anaesthesia). A statistically significant association was found between regional anaesthesia use and dreaming (p = 0.025), suggesting that EEG-guided, opioid-sparing multimodal GA with RA facilitates dreaming. No significant association was observed between opioid use and dreaming (p = 1.0). Dream reporting patients were younger (median 54y (IQR 40-68)) than non-dream reporting (median 62y(IQR 39-69.5))

Dreaming under anaesthesia was common and associated with regional anaesthesia but not opioid administration in MMGA. These findings support the hypothesis that MMGA plus RA increases dream incidence and recall.

Synovial chondromatosis is a rare, benign metaplastic condition of the synovium, characterized by the formation of intra-articular cartilaginous nodules. In advanced stages, joint degeneration may necessitate total knee replacement (TKR). While spinal anesthesia is standard for lower limb arthroplasty, data on its use in rare joint disorders are limited. This case report outlines the anesthetic management of a patient with synovial chondromatosis undergoing TKR under spinal anesthesia.

A 66-year-old male, ASA II, with progressive right knee synovial chondromatosis was scheduled for elective TKR. Spinal anesthesia was performed at the L3–L4 interspace using a 22G pencil-point needle. A total of 3 mL of 0.75% isobaric ropivacaine combined with 20 μg fentanyl was administered. Sensory and motor block onset, intraoperative hemodynamics, surgical conditions, and postoperative analgesia were evaluated.

A sensory block up to T12 was achieved within 4 minutes, with full motor blockade (Bromage 3). Intraoperative conditions were excellent, and the patient remained hemodynamically stable throughout the 120-minute procedure. No additional sedation or analgesia was required. Postoperative analgesia was satisfactory for 6 hours, with no need for rescue medication. No neurological or anesthetic complications were reported.

This case supports the efficacy and safety of spinal anesthesia with ropivacaine-fentanyl combination in complex orthopedic procedures involving rare joint diseases. Regional anesthesia remains a reliable and adaptable technique for individualized perioperative management.

We report a case of inadvertent migration of the epidural catheter into the thoracic paravertebral space, which was recognized in unilateral hypesthesia and was confirmed by epidurography and CT scan.

A 63-year-old woman, height 151cm, weight 82kg and body mass index 36, was scheduled to undergo laparoscopic right partial nephrectomy under general and epidural anesthesia. Epidural puncture was performed in the left lateral position at T11-12 interspace through left paramedian approach. After several attempts, loss of resistance was obtained at a depth of 8cm, and the catheter was inserted 5cm cephalad. General anesthesia was maintained with propofol and remifentanil 0.1μg/kg/min or less. Prior to skin incision, mixture of 3ml ropivacaine 0.75%, 100μg fentanyl and 3mg morphine was administered through the catheter.

Throughout the operation, her blood pressure and heart rate were stable, and her postoperative pain control was good. But a day after the operation, her hypesthetic dermatomal level was T8-10 on her right side, while no hypesthesia was detected on the left. Epidurography and CT scan with contrast injection through the catheter revealed catheter migration into the right thoracic paravertebral space and enhancement of the same area. It is suspected that the Tuohy needle was advanced beyond the midline. Paramedian approach and deep insertion distance may have contributed to the inadvertent migration into the paravertebral space.

When performing epidural puncture, we should be aware that accidental migration of epidural catheter into the paravertebral space might occur. Epidurography and CT scan was useful in identifying epidural catheter migration.

With an ageing population, the number of total hip arthroplasty (THA) procedures is steadily increasing, accompanied by a notable mortality rate of 5.8%. This study aimed to compare the economic impact of general anaesthesia (GA) versus spinal anaesthesia (SA) in patients undergoing THA in Croatia, focusing on overall hospital costs and transfusion-related outcomes.

A retrospective analysis was conducted using data from Clinical Hospital Zagreb. The study included 165 patients who underwent THA in 2012—64 under GA and 101 under SA. Total hospital costs were calculated, including material use, medications, blood transfusions, and postoperative complications. Transfusion rates and related expenses were also assessed.

Total costs were significantly higher for the GA group (€44.58) compared to the SA group (€11.18) (p < 0.0001). Blood transfusion rates were 81.1% in the GA group and 62.9% in the SA group (p = 0.94), with the average cost of transfusion estimated at €54. Although transfusion rate differences were not statistically significant, SA was associated with reduced blood loss and overall economic burden.

Spinal anaesthesia in THA is associated with significantly lower hospital costs and reduced transfusion needs. Cost-saving strategies should include the wider use of regional anaesthesia, implementation of restrictive transfusion protocols, correction of preoperative anaemia (e.g., IV iron ± erythropoietin), use of tranexamic acid, and autologous transfusion techniques. Investing in training for regional anaesthesia could yield substantial economic and clinical benefits.

In spinal anesthesia, baricity determines intrathecal drug spread and block characteristics. Hyperbaric bupivacaine is widely used for lower limb arthroplasties. In our institution, it is routinely combined with preservative-free morphine to enhance postoperative analgesia. While this combination is common in clinical practice, its physicochemical effect on baricity has not been quantified. We aimed to evaluate the density - and hence baricity - of this custom-made intrathecal mixture.

The density of hyperbaric bupivacaine (Marcaine® Spinal 0.5% Heavy), morphine (100 µg/mL in saline), and their 2.2:1 mL and 2.4:1 mL (Marcaine®:morphine) mixtures were measured at room temperature using the Menarini Aution MAX AE-4030 system. Three samples of each solution were analyzed. Theoretical calculations were performed for validation.

Mean measured densities (standard deviation) in g/cm³ were: morphine 100 µg/mL: 1.004 (0.001); hyperbaric bupivacaine: 1.029 (0); mixture (2.2 + 1 mL): 1.021 (0.001); mixture (2.4 + 1 mL): 1.021 (confirmed in duplicate). Theoretically calculated densities for these mixtures were 1.0212 and 1.0216 g/cm³, respectively. Despite the dilution, the final mixture remains hyperbaric relative to CSF (~1.0003 g/cm³ at 37°C).

This is the first study to quantify the baricity of a commonly used morphine–bupivacaine spinal mixture. Although addition of the morphine solution lowers the density of hyperbaric bupivacaine, the mixture remains hyperbaric, supporting its continued clinical use with expected spread behavior. These findings reinforce the importance of physicochemical validation in custom-made intrathecal preparations.

Managing quadriplegic patients for non-spinal surgery remains challenging due to the complex pathophysiological changes associated with spinal cord injury (SCI). Autonomic dysreflexia (ADR), a life-threatening complication triggered by surgical stimuli below the level of injury, most commonly of urologic origin, requires particular attention. This case report presents the anesthetic management of a quadriplegic patient undergoing an urologic procedure, emphasizing strategies to prevent ADR.

A 79-year-old, ASA III, male patient with a history of C5 SCI and cervical spine surgery six months ago, was scheduled for suprapubic catheter placement for a neuropathic bladder. Preoperative evaluation revealed normal cardiac function and a restrictive ventilatory pattern with small airway disease. His medication included fondaparinux, famotidine, filicine, d-mannose, alprazolam and ciprofloxacin. Laboratory tests were within normal limits. No episodes of ADR were reported. After obtaining informed consent, the patient was placed in the lateral decubitus position under standard monitoring, and 2.6 ml of 0.5% levobupivacaine was administered intrathecally. A nitroglycerin infusion (1 μg/ml) was prepared for immediate use in case of ADR.

The procedure lasted 35 minutes and the patient remained hemodynamically stable. No signs of ADR were observed during bladder distension. The exact level of the subarachnoid block could not be determined intraoperatively, highlighting a common limitation in the intraoperative assessment of sensory block levels in SCI patients.

This case supports the safety and effectiveness of regional anesthesia for preventing ADR in SCI patients undergoing urologic procedures. Given the variability in presentation and risks, individualized anesthetic planning remains essential for optimal outcomes.

The impact of substance abuse on traumatic injuries is of serious concern in today’s world. Data from the Australian registry shares substance use in major trauma to be higher than in the general population¹ Nearly 40% of deaths due to trauma had positive alcohol or toxicology screens. We share a case presenting with acute cocaine, marijuana, polypharmacy toxicity requiring emergency surgery for fracture femur²

A 60yr old male, presented after a fall from a height. In discussion he shared use of Cocaine, Marijuana & polypharmacy, prior to and after sustaining the injury. Plan was ORIF to fix the Left subtrochanteric femoral fracture. On anaesthetic review, the patient was noted to be extremely drowsy, unresponsive at times, slurring speech. His heart rate was 60b/min with a BP of 172/94mmHg, normal QTc, apyrexial. CT brain revealed right caudate nucleus, corona radiata ischemic infarct. We debated the possibility of the CVA leading to the fall. On assessment as the pupils were pin point a trial of naloxone was performed eliciting reversal and GCS of 15/15 with normal neurology.

Taking into account acute cocaine, marijuana and possible drug use, a spinal anaesthetic was determined to be appropriate². The patient had an ORIF with cerclage and TFNA nail which was uneventful and was discharged a week later³

Substance misuse is associated with higher odds of inpatient medical adverse events, prolonged hospital stay and non-routine discharge after orthopaedic trauma³ Emphasis on appropriate investigations, associated diagnosis, prompt recognition and proactive treatment measures may support effective trauma management

We report a case of epidural catheter migration into the thoracic paravertebral space, which was recognized because of unilateral hypesthesia and confirmed by epidurography and computed tomography (CT).

A 63-year-old woman (height 151 cm, weight 82 kg, body mass index 36) was scheduled to undergo laparoscopic right partial nephrectomy under general and epidural anesthesia. Epidural puncture was performed in the left lateral position at the T11-12 intervertebral space via a left paramedian approach. After several attempts, loss of resistance occurred at a depth of 8 cm, and the catheter was inserted 5 cm cephalad. General anesthesia was maintained with propofol and remifentanil 0.02-0.1 μg/kg/min. Before skin incision, a mixture of 3 ml ropivacaine 0.75%, 100 μg fentanyl, and 3 mg morphine was administered via the catheter.

Intraoperative blood pressure and heart rate were stable, and postoperative pain control was good. The day after the operation, however, the T8-10 dermatomal level was hypesthetic on the right side, whereas no hypesthesia was detected on the left. Epidurography and CT with contrast injection through the catheter revealed catheter migration into the right thoracic paravertebral space and enhancement of the same area. We suspect that the Tuohy needle was advanced beyond the midline. The paramedian approach and deep insertion distance may have contributed to the migration into the paravertebral space.

When performing epidural puncture, we should be aware that epidural catheter migration into the paravertebral space might occur. Epidurography and CT was useful for identifying this migration.

Epidural anesthesia is a frequently used advanced medical procedure with a variety of possible catastrophic complications. Training novice anesthesia residents in epidural catheter placement necessitates comprehensive anatomical knowledge and precise execution of the loss-of-resistance technique. The Epifaith syringe, an innovative tool employing springs and fixators, visualizes the loss of resistance phenomenon. This study aimed to educate novices on the epidural space localization using the Epifaith syringe.

Fifteen final-year medical students participated as volunteers. They received a 20-minute briefing on the epidural space anatomy, physiology, localization techniques, and potential complications from an expert in regional anesthesia. A two-minute instructional video from the manufacturer combined with a recording of Epifaith syringe usage on a patient followed. A five-minute Q&A session preceded live demonstrations on an epidural model. Each student performed three localization attempts, with time to localization, needle redirections, accidental dural punctures, and unsuccessful attempts recorded across 45 trials.

Initial success in reaching epidural space was common, averaging 14.5(±9.17) seconds per attempt; maximum needle redirection was three instances. One false-loss event occurred, attributed to the interspace between the bone and the soft tissue parts of the model. Post-study surveys indicated ease of use with the Epifaith syringe among the participants.

The device offers educational value for novice users in epidural catheter placement by enhancing visualization and dexterity through dual-handed operation. Despite limitations such as non-clinical settings and participants' limited experience with complications, findings suggest that the Epifaith syringe may be beneficial for training in novice education.

Loss-of-resistance (LOR) is the standard method for epidural space identification, though its tactile feedback can be subtle. This study compared a spring-loaded syringe (Epifaith), designed to provide visual feedback, with a conventional LOR syringe (B. Braun) in patients undergoing lower limb orthopedic surgery.

Fifty-six patients scheduled for lower limb orthopedic procedures under combined spinal-epidural anesthesia (CSEA) were randomized to either the Epifaith group (n = 28) or the B. Braun group (n = 28) after ethical committee approval. Demographic data, epidural space depth, time to identify epidural space, number of needle redirections, and number of intervertebral levels attempted were collected. Normality was assessed with the Shapiro-Wilk test; comparisons used the Mann-Whitney U or Student’s t-test as appropriate.

Demographic characteristics and epidural space depth were similar between groups. The median time to identify epidural space was 81 seconds in the Epifaith group and 53.5 seconds in the LOR group (Mann-Whitney U = 500.0, p = 0.078). Median number of needle redirection was 1.5 (Epifaith) vs. 2.0 (B. Braun) (U = 364.0, p = 0.630). The number of intervertebral levels attempted was similar in both groups (median = 1.0; U = 407.0, p = 0.773). The surgery was successfully completed under CSEA for all patients without any complications.

The spring-loaded syringe did not significantly alter procedure time, needle redirection, or technical difficulty compared to the LOR syringe in epidural space identification.

Combined spinal-epidural anesthesia (CSEA) is widely used for cesarean delivery, requiring accurate identification of the epidural space to ensure success and safety. Traditional loss of resistance (LOR) technique is operator-dependent, and spring-loaded autodetect syringes have been developed to provide visual and tactile feedback, potentially improving reliability and procedural control. The aim of this case series is to evaluate the efficacy and procedural characteristics of a spring-loaded, autodetect syringe during CSEA for cesarean delivery.

The clinical records of patients who underwent elective cesarean section with CSEA using a spring-loaded autodetect syringe between May and June 2025 were retrospectively reviewed. Data regarding time to identify epidural space, number of needle redirections, and any potential complications were analyzed. All patients provided written informed consent for the anonymized use of their clinical data prior to the procedure.

Twelve elective cesarean section procedures were performed using the Epifaith spring-loaded autodetect syringe for epidural space identification. All procedures were successfully completed. The mean time to identify epidural space was 94.3 ± 83.6 seconds (median: 65 seconds), and the average epidural depth was 4.75 ± 0.9 cm. The mean number of levels attempted was 1.17 ± 0.4, and the mean number of needle redirections was 2.17 ± 1.9. No complications were observed.

This case series suggests that the spring-loaded autodetect syringe may facilitate safe and effective identification of the epidural space in cesarean delivery.

Patients with preexisting pulmonary disease are highly susceptible to intraoperative respiratory complications and have a higher incidence of postoperative pulmonary complications (PPCs), such as postoperative hypoxia and pneumonia, particularly under general anaesthesia (GA) and mechanical ventilation. In contrast, neuraxial anaesthesia (NA) has demonstrated superiority in reducing PPCs, preserving spontaneous ventilation, and minimizing systemic inflammatory responses.

This report describes the anaesthetic management of a 63-year-old male with stage IV Pancoast lung adenocarcinoma and widespread metastases, under palliative care, admitted for surgical fixation of a pathological subtrochanteric femoral fracture. Relevant comorbidities included virally suppressed HIV, bullous emphysema, and post-tuberculosis pulmonary sequelae. Clinical evaluation revealed productive cough, coarse pulmonary auscultation, and hypoxemia. Laboratory studies showed elevated inflammatory markers, and sputum cultures identified Moraxella catarrhalis and Pseudomonas aeruginosa, for which antibiotic therapy was initiated. Considering the elevated risk of PPCs, a neuraxial approach was selected. A single-shot subarachnoid block with 10 mg levobupivacaine and 2.5 µg sufentanil was performed. Spontaneous ventilation was preserved with supplemental oxygen at 2 L/min via nasal cannula. Multimodal analgesia incorporated intravenous acetaminophen, parecoxib and ultrasound-guided femoral and lateral femoral cutaneous nerve blocks with 0.2% ropivacaine.

The postoperative course was uneventful, and he was discharged without complications after 3 days.

Hip fractures are extremely painful and result in increased patient morbidity, such as decreased overall functional status and mobility. This case highlights the critical role of regional anesthesia in the anesthetic management of a hip fracture patient at a high risk for PPCs.

Airway management in patients with head and neck malignancies is frequently complicated by anatomical distortion and a high risk of obstruction. In some cases, even awake intubation may be unfeasible due to the inability to advance the orotracheal tube. Regional anesthesia techniques may offer a safer alternative to general anesthesia. This case highlights the successful use of bilateral intermediate cervical plexus block (ICPB) and translaryngeal block for urgent tracheostomy in a patient with advanced hypopharyngeal cancer.

A 63-year-old male with a history of alcohol and tobacco use and hypopharyngeal squamous cell carcinoma (cT3N2bM0) presented with resting dyspnea and oral mucosal bleeding. Otolaryngologic assessment identified an ulcerated tumor of the right pyriform sinus, right vocal cord paresis, and severe glottic narrowing. Due to imminent airway compromise, urgent tracheostomy was indicated. An ultrasound-guided bilateral ICPB was performed with 5 mL of 0.75% ropivacaine on each side. Also, we performed an ultrasound-guided translaryngeal block with 4 mL 2% lidocaine. No sedation was administered.

A sensory block covering dermatomes C2 to C4, along with the trachea and lower larynx, was successfully achieved. The procedure was completed without complications, and the patient remained awake and comfortable throughout. The postoperative course was uneventful, with no pain reported. On the fifth postoperative day, the patient was transferred to a specialized oncology center for ongoing care.

Bilateral ICPB combined with a translaryngeal block provided adequate anesthesia and patient comfort during urgent tracheostomy without the need for general anesthesia or sedation. This approach represents a safe and effective alternative for urgent tracheostomy in patients with compromised airways.

High-risk pulmonary embolism (PE) in elderly patients can complicate lower limb fractures, posing a challenge for anesthetic management. We describe a case of how targeted peripheral nerve blocks (PNBs) balanced urgent fracture fixation with thromboembolic risk management in a patient with fracture-related PE.

A 92-year-old female proposed for open reduction and internal fixation of a supracondylar femoral fracture presented with acute bilateral PE (PESI class V), type 1 respiratory failure, and new-onset atrial fibrillation. Significant comorbidities included chronic kidney disease and prior cerebrovascular disease. To optimize perioperative management, therapeutic enoxaparin was transitioned to unfractionated heparin preoperatively, with discontinuation 4 hours prior to surgery. We performed a combination of ultrasound-guided PNBs: (1) a femoral nerve block (5 mL mepivacaine 1.5% + 10 mL ropivacaine 0.5%), (2) a lateral femoral cutaneous block (2 mL mepivacaine 1.5% + 3 mL ropivacaine 0.5%), and (3) a transgluteal approach to block both the posterior femoral cutaneous and sciatic nerves (5 mL mepivacaine 1.5% + 10 mL ropivacaine 0.5%). Sensory blockade was confirmed in all target nerve distributions prior to surgical incision. Sedation with propofol was then administered for patient comfort, and mechanical thromboprophylaxis was maintained throughout the procedure.

Surgery was completed within 80 minutes without complications. Excellent intraoperative anesthesia and postoperative analgesia was achieved, with documented patient satisfaction and no need for rescue analgesia. Anticoagulation with enoxaparin was restarted 12 hours postoperatively. The patient initiated physical rehabilitation on postoperative day 1 and was discharged on day 4.

Ultrasound-guided PNBs safely avoided neuraxial and general anesthesia risks in this patient with acute PE, permitting timely anticoagulation resumption and early mobilization. The successful outcome underscores the importance of timely surgical fixation in hemodynamically stable patients with fracture-related PE, as it may prevent thromboembolic progression. PNBs can be an alternative as primary anesthetic technique in complex cases.

Hip fractures in elderly patients with severe aortic stenosis present significant anesthetic challenges, as neuraxial techniques carry risks of hemodynamic instability. This case demonstrates the use of ultrasound-guided combination of peripheral nerve blocks as the sole anesthetic approach in a high-risk patient.

A 90-year-old autonomous woman with severe aortic stenosis and dyslipidemia underwent surgery for a subcapital femoral fracture. Ultrasound-guided subgluteal sciatic, obturator, and fascia iliaca blocks were performed. Light sedation with midazolam was administered intraoperatively. The patient remained hemodynamically stable throughout the procedure, with no need for vasopressor support or complementary opioid analgesia.

The avoidance of neuraxial anesthesia minimized the risk of hypotension and myocardial ischemia associated with severe aortic stenosis. This strategy enabled the surgery to be performed safely in a peripheral center without intensive care support, avoiding delays and transfer. The case highlights the versatility and safety of regional anesthesia, particularly in frail patients with high perioperative risk and in settings with limited resources.

Ultrasound-guided peripheral nerve blocks are a safe and effective alternative to neuraxial anesthesia in patients with severe aortic stenosis undergoing hip fracture surgery. This approach may reduce morbidity and mortality, and allows timely surgical management even in non-tertiary centers.

Anaesthetic management of patients with severe sepsis requiring urgent surgery pose significant challenges. This case reports the perioperative management of a 73-year-old female with multiple comorbidities (hypertension, type 2 diabetes mellitus, osteoarthritis, Heavy smoker, respiratory sepsis, COPD) who sustained a Tri malleolar ankle fracture with moderate displacement. She required an urgent orthopaedic intervention to prevent limb compromise.

The patient presented with an ankle fracture and respiratory sepsis (fever, productive cough, widespread crackles, hypoxia requiring oxygen and broad-spectrum antibiotics). Investigations revealed CRP 263 mg/L, WCC 52 x10⁹/L (neutrophils 48 x10⁹/L), and pneumonia on chest X-ray. Attempted manipulation under sedation by surgeons in A&E failed, necessitating urgent theatre intervention due to limb compromise. General anaesthesia (GA) was high-risk due to chest condition, and spinal anaesthesia was contraindicated due to severe respiratory sepsis. Therefore, a regional anaesthetic approach was chosen. Ultrasound-guided popliteal sciatic and saphenous nerve blocks with levobupivacaine (0.25% and 0.5%) were performed. For anxiolysis, she received 25 mcg fentanyl and 0.5 mg midazolam. Closed reduction was successfully achieved under regional anaesthesia. ORIF was deferred until sepsis was optimized.

Peripheral nerve blocks provide safe and effective anaesthesia in septic, high-risk patients, minimizing systemic complications and avoiding airway intervention. However, with strict asepsis and US guided approach, the blocks were performed safely and successfully. In addition, delaying ORIF ensured optimal infection control before definitive fixation.

Regional anaesthesia, particularly peripheral nerve blocks, offers a viable alternative to General or spinal anaesthesia, emphasizing a multidisciplinary, patient-centred approach for improved outcomes in complex cases. All trainees need to be taught PLAN-A, RAUK blocks as per the RCOA curriculum recommendations. By undertaking this procedure under regional block, avoided patient limb compromise. RA-UK PLAN -A blocks workshop is now regularly taught in our institute for all the trainees and anaesthesia fellows .

We report a case of combining femoral and popliteal sciatic nerve blocks as the main anesthetic technique in an ASA III patient undergoing urgent reconstruction of an infected soft tissue defect of the left lower tibia using an autologous propeller flap.

A 46yo patient was admitted with COPD exacerbation, in need of oxygen supplementation and had recently(<12h) received thromboprophylactic dose of LMWH. Due to the significant perioperative risk, ultrasound guided femoral and popliteal nerve blocks were elected as the main anesthetic technique. Preoperatively, under sterile conditions, with the patient in supine position, a high-frequency linear transducer was placed transversely over the femoral crease and the femoral nerve was identified. A femoral nerve block was performed, with 7ml ropivacaine 0,5% and 3 ml lidocaine 2%. The transducer was again placed transversely at the popliteal fossa and popliteal artery, tibial and common peroneal nerve were visualized. After sliding the probe proximally, to identify the sciatic nerve in Vloka’s sheath, 25ml of ropivacaine 0,5% and 5ml lidocaine 2% were administered.

Surgical anesthesia, with complete sensory and motor block of the left lower limb, was achieved. The surgery was well tolerated with IV sedation: 2 mg midazolam, 50μg fentanyl and propofol TCI (2μg/ml). No adverse effects were recorded.

The combination of femoral and popliteal sciatic nerve blocks was an effective regional technique, allowing this high-risk patient to undergo lower limb surgery, while avoiding general anesthesia and central neuraxial blockade.

While MRM is typically performed under GA, regional analgesia might lower the cardiovascular and respiratory complications in high-risk patients. In this case report, we present a 40-year-old female who had an anaphylactic shock and underwent 6 cycles of CPR following cefuroxime AST, EF of 45% and chronic bronchitis. Despite these challenges, she successfully underwent MRM for stage 3b breast carcinoma under combined thoracic paravertebral and serratus anterior plane block with total intra venous anaesthesia.

After obtaining high risk consent and two large bore IV cannulas and standard monitors, USG guided right PVB at T2-T3, T3-T4 level was administered. She was induced with fentanyl and propofol and pro-seal LMA was placed. Muscle relaxant was not given. Propofol TIVA was started at 250mg/hr. Post induction, USG guided right SAPB was given at 4th and 5th ribs.

Hemodynamic stability was achieved. Muscle relaxant necessity was not present. Opioid requirement was nil intra-operatively and postoperatively. She was pain-free in the post-operative period.

Thus, combined thoracic PVB with SAPB along with TIVA is an alternative anesthetic modality for MRM surgeries. It avoided perioperative anaphylaxis, provided stable hemodynamic, post operative analgesia for a patient having multiple cardio-respiratory co-morbidities.

Peripheral nerve injury from regional anaesthesia is rare but can have significant consequences. We audited the use of SAFIRA®, a novel device enabling single-operator peripheral nerve blockade (PNB). SAFIRA® automates injection of local anaesthetic (LA), stopping at a pre-set pressure to reduce the risk of nerve injury.

Twelve anaesthetists with varying experience trialled SAFIRA®. A target of 30 feedback responses was set. Users completed subjective evaluations after each use via virtual forms linked to QR codes on equipment.

Of the blocks performed, 53% were by consultants, 24% by senior trainees, and 23% by junior trainees. 80% were upper limb blocks and 20% lower limb; no fascial plane blocks were recorded. All participants agreed that minimising nerve injury was extremely important. However, only 3% and 7% were extremely confident in their assistant’s delivery of correct LA volume and safe injection pressure, respectively. Over 80% used the foot pedal, the rest used the palm operator. 27% found SAFIRA® very easy to use; 63% said it became easier with practice. One anaesthetist found it difficult. 97% used the same or less LA volume than in two-person techniques, and 70% were highly confident in the device’s pressure control. 60% saw SAFIRA® as useful for training. Common criticisms included the need for extension tubing, device repositioning, and the lack of audible alerts.

SAFIRA® was well received, with usability improving over time. Suggested improvements include better ergonomic design and audio alerts to enhance user experience.

Although rare, peripheral nerve injuries represent significant complications in orthopedic surgery, often arising from multiple perioperative factors including patient positioning, regional anesthesia techniques, tourniquet pressures, and inflation duration. We aim to report a case of multifactorial upper limb neuropathy following wrist surgery under combined regional and general anesthesia, discussing its potential etiologies and clinical outcome.

We present the case of a 44-year-old healthy male who underwent open and arthroscopic fixation of a scaphoid fracture with bone graft interposition. An ultrasound-guided axillary brachial plexus block was performed with 25 ml of 0.5% ropivacaine, followed by balanced general anesthesia. A pneumatic tourniquet was inflated to 220 mmHg for 2 hours and 8 minutes, while the patient's intraoperative systolic blood pressure averaged 90 mmHg, consistent with his usual baseline values. The procedure was uneventful, with no intraoperative complications reported.

The patient was discharged from the post-anesthesia care unit with partial regression of the brachial plexus block. At 60 hours postoperatively, by which time complete resolution would have been expected, he continued to exhibit difficulty flexing the elbow, paresthesia in the median and ulnar nerve territories, and weak biceps contraction. Electromyography confirmed mild lesions of the musculocutaneous, median, and ulnar nerves. A multifactorial etiology was considered, involving the nerve block, prolonged tourniquet inflation, and mechanical compression. He required intensive physiotherapy and achieved near-complete neurological recovery within five months.

Peripheral nerve injury following upper limb orthopedic surgery can result from a combination of factors, including nerve blocks and tourniquet use. Tourniquet pressures should not exceed 100 mmHg above systolic blood pressure, and application time should be limited to 2 hours. Early diagnosis and multidisciplinary management are essential for recovery. This case highlights the importance of preventive strategies and careful intraoperative planning to minimize nerve injury risk.

Method of thermography has been proven to be useful for confirming the success or failure of for various nerve blocks. However, according to literature, majority of these nerve blocks have been done on elective patients. In our study we wanted to determine, can method of thermography can be used to determine success of a n.ischiadicus blocks in acute lower limb fractures where the initial skin temperature around fracture site is already high?

A prospective, randomized research done in the Hospital Of Traumatology and Orthopedics in Riga. In total 48 patients where collected of which 35 were elective and had 13 acute bone fractures. These 13 patients are analyzed further below. All patients recieved N. ischiadicus block in suprapopliteal approach, using ultrasound and nerve stimulator with 3 different local anesthetics in equipotent doses and fixed concentrations- 20ml of 0.25% bupivacaine, 20 ml of 1% Lidocaine, 20ml of 0.375% Ropivacaine. Before and for 45 minutes after nerve block for every minute pictures of the blocked foot were taken. Pictures were analysed using HICKMICRO official software program, with statistics done by University of Latvia Statistics Laboratory.

Due to relatively small sample size, all 13 patients were analyzed as one group. All of these patients had initial temperature of the foot above 32 degrees Celsius. According to Wilcoxon range tests, statistically significant (p<0.05) temperature changes compared to baseline can be observed after 25 minutes.

Although using method of thermography for evaluating success of n.ischiadicus block in acute fractures, where initial temperature of the blocked region exceeds 32 degrees Celsius, showed statistically significant changes after 25 minutes compared to baseline temperature, the changes of temperature in blocked region are relatively small and slow, making them difficult to detect in clinical practice application conditions.

At Fundación Hospital de Alcorcón, we conducted a prospective observational study to evaluate the efficacy of continuous femoral nerve block (CFNB) using a perineural catheter for postoperative analgesia in patients undergoing anterior cruciate ligament (ACL) reconstruction.

Our primary objective was to assess pain control and our secondary objective was to reduce opioid use and related adverse effects such as nausea, vomiting, sedation, and delayed discharge. At the end of surgery, a 300 ml elastomeric pump delivering 0.125% levobupivacaine at 10 ml/h was initiated. All patients received scheduled paracetamol and dexketoprofen as part of a multimodal analgesia regimen.

We initially included 27 patients; 3 were excluded due to unreachability by phone, and 1 due to a technical issue with the catheter connection. Pain was assessed using a Verbal Numeric Scale (VNS) and need for rescue analgesia with tramadol. At 1, 6, 12, 24, and 48 hours postoperatively, 17, 15, 17, 18, and 16 patients respectively reported VNS scores under 5. Only 10 patients required rescue analgesia with tramadol, indicating adequate baseline pain control. Seven patients were successfully discharged the same day. Of those who stayed overnight, only four remained due to pain. Other reasons for overnight stay included patient preference, drain output, or pending orthopedic evaluation. No patient required readmission or emergency care for pain. There were no reports of infection, mobility limitations, or significant complications related to the catheter. Patients described the system as easy to use and remove, and all expressed willingness to undergo the same procedure again if needed.

This approach supports effective multimodal analgesia that limits opioid use and facilitates outpatient management, potentially offering a cost-effective solution for postoperative care after ACL reconstruction.

The erector spinae plane block (ESPB) has emerged as a promising regional anesthesia technique for thoracoabdominal procedures. Its role in enhanced recovery after surgery (ERAS) pathways for open gynecologic surgeries remains under investigation. Traditional analgesic techniques such as transversus abdominis plane (TAP) blocks primarily target somatic pain, while the ESPB may offer broader coverage, including visceral pain, by engaging thoracolumbar sympathetic fibers. This cadaveric study aimed to evaluate the anatomical spread of local anesthetic from ESPB injections and its implications for sensory blockade of the abdominal wall.

A fresh, non-embalmed adult male cadaver was used. Two ESPBs were performed: a single-shot 40 mL injection at the T8 level on the left side and a catheter-based 40 mL injection at the T4 level on the right. Both injectates included blue dye and radiopaque contrast. Real-time fluoroscopy was used during injection to assess cephalocaudal spread, followed by anatomical dissection to evaluate dye distribution across neural and fascial structures.

Fluoroscopy showed extensive vertical spread of contrast. (Figure 1) Dissection revealed dye diffusion from T3 to T12 on the left and from T1 to T8 on the right, tracking anterior and deep to the erector spinae muscles. (Figure 2A) Injectate extended into the paravertebral and intercostal spaces. (Figure 2B) There was no evidence of dye in the dorsal root ganglion, epidural space, or anterior sympathetic chain.

Cadaveric studies have been done for the ESPB with varying results. Our own large-volume injectate and catheter injection study is in-line with studies that demonstrated extensive dermatomal coverage as well as paravertebral spread. This suggests potential coverage of the thoracolumbar sympathetic nerves responsible for both abdominal wall somatic and visceral sensations, which supports the feasibility of ESPB as an adjunct for postoperative analgesia in open gynecologic procedures, warranting further clinical investigation.

Different analgesia pathways exist for total hip replacement surgery (THR). We analyzed a difference in efficacy, safety and satisfaction of analgesia depending on analgesia pathways for THR surgeries.

Prospectively 31 ASA II – III, 8 male, age 67.8 ± 6.7 y. THR surgery were analyzed. Approval No. 2-PĒk-4/335/2025. Spinal anesthesia (SA) with isobaric Bupivacaine 0.5% 2.8 ml and either intrathecal morphine 100mcg (M group, n = 10), fascia iliaca infraingvinal block with Bupivacaine 0.25% 30ml (FIB group, n = 11), intrathecal morphine 50mcg and FIB (M +FIB group, n =10) and multimodal analgesia after surgery were used. As a primary outcome pain intensity (NRS scale) 8 and 24 hours (h) after surgery, secondary – satisfaction (QoR 15 scale), safety issues were analyzed. SPSS, p< 0.05.

Preliminary results - 8 h pain was higher in FIB (5.8 ± 3.0) vs. M (2.2 ± 2.3) and M+FIB (2.3 ± 2.1); P<0.05. After 24h pain differed between FIB (4.7 ± 2.1) vs. M (2.1 ± 2.1), not anymore vs. M + FIB (3.5 ± 3.0); p = 0.049, p =0.49, respectively. Difference was not found in QoR 15 scores comparing M (122 ± 16.6), FIB (126.5 ± 16.1), M +FIB (113 ± 32.8). A trend to lower satisfaction in PONV in M (8.1 ± 3.5) vs. FIB (9.91 ± 0.3), M +FIB (9.8 ± 0.4). Hypotension postoperatively was detected in M group for 2, M + FIB for 1 cases.

Morphine 100mcg to SA more effectively reduce pain comparing to FIB and lower Morphine dose with FIB after THR without significantly affecting satisfaction. However, PONV, hypotension might be more often expected.

Background: Bronchoscopy in high-risk patients like lung tumor associated respiratory distress often presents anesthetic challenges due to comorbid conditions that increase the risk of complications from general anesthesia. Aims: We describe a case series involving patients with respiratory distress due to lung tumors who underwent diagnostic bronchoscopy facilitated by upper airway nerve blocks

Methods: This study was conducted on 3 patients who underwent diagnostic bronchoscopy at Dr. Saiful Anwar General Hospital. The patients were given three nerve block, bilateral superior laryngeal nerve block, glossopharyngeal nerve block via lidocaine 2% oral spray, and recurrent laryngeal nerve block (transtracheal) before awake bronschoscophy using 2% lidocaine. We evaluates the patients pain score, complication, gag reflex, glotic closure reflex, and cough reflex

All procedures were completed successfully with minimal complications. Patients demonstrated excellent pain tolerance with effective suppression of the cough, gag, and glotic closure reflex. Intraoperative hemodynamics remained stable throughout

Regional airway blocks offer a safe, effective alternative for lung tumor associated respiratory distress patients requiring diagnostic bronchoscopy.

Given the rising global demand for breast cancer surgery, Hospital del Mar is testing a new care circuit for breast-conserving surgery using local or regional anaesthesia with sedation as an alternative to general anaesthesia. If successful, this approach may reduce time in the operating theatre and the post-anaesthetic care unit (PACU). This case series aims to describe our initial experience and assess patient and professional tolerance and satisfaction.

We report a prospective case series of five patients undergoing lumpectomy under regional or local anaesthesia with minimal to moderate sedation. Three received deep serratus anterior plane block (d-SAPB) and pecto-intercostal fascial plane block (PIFP), one received d-SAPB plus local infiltration, and one underwent local infiltration only.

In this case series, no patients required conversion to general anesthesia, and none reported postoperative pain above 3 on the visual numeric scale. Eighty percent were discharged the same day; the rest were admitted for social reasons. At the two-month follow-up, four out of five reported high satisfaction (measured by the EVAN-LR questionnaire) and expressed willingness to repeat the procedure under the same conditions. One patient did not, due to vomiting that was resolved with medication. The surgical team rated the experience positively, with no technical issues or complications.

This five-case series demonstrates the safety, efficacy, and patient tolerance of a locoregional anaesthesia-sedation circuit for breast-conserving surgery. Its use may improve resource efficiency, enhance the patient's experience, and has been positively evaluated by the medical team.

Systemic toxicity from local anesthetics is a rare, yet often lethal complication. We present a case of local systemic toxicity following a femoral nerve block in a 68-year old patient who underwent a total knee arthroplasty. Our aim is to raise awareness among colleagues to identify the first signs of this condition, as well as suggest appropriate patient management.

The patient was a 68-year-old female (ASA II), with a patient history of hypertension, managed by a b-blocker. Pre-op clinical examination and lab tests were normal. An ultrasound-guided femoral nerve block was performed post-op for analgesia, after the patient had undergone a left total knee arthroplasty. A solution of 20 ml 0,2% ropivacaine was administered. The patient began to experience a metallic taste and tongue numbness, and appeared disorientated. Vital signs were 80/40 mmHg, 98% Sp02, 42 bpm. Systemic toxicity was suspected. One dose of 1.5 ml/kg of 20% intravenous lipid emulsion was administered, followed by continuous infusion. The patient was promptly intubated and supported with fluids and vasopressors. She was transferred to the ICU.

The patient was extubated 48 hours later without complications.

Systemic toxicity of local anesthetics can be life-threatening, and clinical symptoms may often initially be mild. It is often believed that systemic toxicity arises when using large volumes of local anesthetics, however this case report reveals that it may present even when using appropriate volumes. Identifying symptoms quickly is key in order to prevent devastating outcomes.

Open hysterectomy is often associated with significant postoperative pain. Multimodal analgesia strategies, especially opioid-sparing approaches, are therefore recommended. Abdominal wall nerve blocks (AWB), including the transversus abdominis plane (TAP) and quadratus lumborum (QL) blocks, are gaining popularity in this setting. These blocks mainly target somatic innervation, although QL may offer extended analgesia due to potential paravertebral spread.

This retrospective study included 40 women who underwent elective open hysterectomy between January 2023 and December 2024 at a tertiary center and received either a TAP or QL block. Data collected included demographics, ASA status, type of block, anesthetic dose, postoperative pain (numeric scale 0–10), need for rescue analgesia, opioid use, and complications within 72 hours.

Mean age was 53 years; 75% were ASA II. TAP was performed in 55% and QL in 45%, using ropivacaine (0.2–0.75%). Mean of postoperative pain score was 1.28 ± 1.20, higher in TAP (1.5 ± 1.4) than QL (1.0 ± 0.9), without statistical significance (p = 0.193). Rescue analgesia in the recovery unit was required in 82.5% (72% opioids); 12.5% needed opioids in the first 24h — more frequent in TAP (18.2%) than QL (5.6%). No complications were observed.

These results support AWBs as safe, effective elements of multimodal analgesia in open hysterectomy. Despite the absence of statistically significant differences, QL blocks were associated with lower pain scores and reduced need for opioids. The absence of short-term complications reinforces their safety profile.

Transient myoclonic involuntary movements of the extremities and trunk, which are defined as spinal myoclonus (SM), rarely develop after neuraxial anesthesia. In this case report, we aimed to present strong spinal myoclonic activity at lower extremity which no operated.

A 50-year-old American Society of Anesthesiology (ASA) physical status I man underwent surgery for left leg varices. Standard monitoring (EKG, noninvasive blood pressure and pulse oximeter) was applied to the patient. Spinal anesthesia performed with 3 ml of 0.5% hyperbaric bupivacaine at the L4-L5 level by a 25G pencil point spinal needle. A sensory block tested with pin prick technique. The block level determined at T7-T8. Surgical saphenous venous ligation performed by surgeon. Surgery duration was 80 min. The surgery proceeded uneventful and then the patient was sent to the ward. At the postoperative 1th hour, the patient complained involuntary movement at no operated leg. He described movements first at right foot then right leg. Sensorial block level was at T7-T8 and motor block was 2/5 for both legs. His involuntary movements continued till the postoperative 24th min. The patient consulted by neurology specialist and evaluated with cranial and spinal magnetic resonance imaging (MRI) and computer tomography (CT). MRI and CT were normal for cranial and spinal imaging. The haloperidol, methylprednisolone and alprazolam were prescript by neurologist.

The patient observed for 3 days postoperatively. Any complication or neurologic neurological damage were not observed and he discharged.

Spinal myoclonus after spinal anesthesia is a rare complication which can disappear without any neurological complication.

Traditional training consists of a trainee assigned to a list with the training opportunities limited to that list. Disadvantages include few cases, operations only needing local anaesthetic, nerve block unsuitability, or patients cancelled on the day of surgery. With pressures on training and the requirement of a minimum number of blocks for exams like EDRA, the RCOA curriculum now encourages floating to widen exposure to a range of clinical experiences. A Block room could also be used but they can be difficult to set up or may need additional funding, therefore a floating trainee is another option.

We employed a new model to increase regional anaesthesia training opportunities. The trainee would be attached to a regular list but could also float to other theatres if regional blocks were needed. For example, the trainee would be attached to a lower limb arthroplasty list but would also be called to perform blocks in our upper limb and trauma lists. This would significantly increase the number of training opportunities available and lead to a greater number of nerve blocks performed.

This model has been very effective at our hospital with excellent feedback from staff, trainees and surgeons. We have been able to increase the number of nerve block opportunities by at least 200%.

The floating trainee system has been very effective in increasing training opportunities whilst not incurring any additional costs. We encourage other hospitals to adopt this model where training opportunities need to be increased and a block room is not feasible.

Total knee arthroplasty (TKA) is a common orthopedic procedure for advanced knee disease. Several anesthetic techniques may be used to provide surgical anesthesia for TKA, with peripheral nerve blocks (PNBs) often added to improve pain control and recovery. This study assessed perioperative outcomes in patients undergoing TKA at St. Luke’s Medical Center–Global City (SLMC-GC), focusing on the impact of PNBs on hospital length of stay (LOS).

We retrospectively reviewed the records of 338 TKA cases, comparing postoperative pain score, time to ambulation, incidence of cardiopulmonary complications, incidence of post-operative nausea and vomiting, and LOS. Chi-squared test was used to measure categorical variables, and analysis of variance (ANOVA) for continuous variables. Statistical significance was set at p <0.05.

Neuraxial anesthesia with PNB was the most frequently used technique (n=119, 35.2%). The addition of a PNB to either general or neuraxial anesthesia was associated with a shorter hospital LOS (4.71 ± 2.713 and 4.93 ± 2.945 days, respectively), in contrast to the longer LOS observed with general or neuraxial anesthesia without PNB (7.52 + 3.987 days). No cardiopulmonary complications were recorded in all patients. Although there were no statistically significant differences across all anesthesia techniques in terms of pain score, time to ambulation and incidence of PONV, the addition of PNB appeared to be associated with a lower incidence of PONV (1.8%).

TKA can be safely performed under various anesthesia techniques with comparable perioperative outcomes. However, adding a PNB may reduce hospital LOS and reinforce enhanced recovery after surgery (ERAS) protocols, paving the way for future implementation of ambulatory TKA – an approach that has yet to be adopted in the Philippines.

Trochanteric femoral fractures is most common in eldery patients and associated with high mortality. Anesthesia strategy in elderly involves providing sufficient conditions for surgery while reducing its effects on already impaired cardiopulmonary reserve and cognitive function. We would like to present the anesthesia management in elderly patient with severe aortic stenosis in trochanteric fracture surgery.

CASE REPORT: A 90-year-old patient was admitted for surgery due to fractured femure. The anesthesia plan included administering a peripheral nerve block. Patient had a medical history of severe aortic stenosis with an aortic valve area of 0.84 cm2, hypertension and chronic kidney disease, which complicated with melena after admission. After the gastroenterological treatment and resolution of sympthoms, the patient was scheduled for orthopaedic surgery. An ultrasound-guided PNBs was performed, which included the fascia iliaca block, femoral nerve block, pericapsular nerve group block, and lumbar plexus block. First, an ultrasound-guided (eZono®4000, eZono, Germany) fascia iliaca block was performed in the supine position and 10ml of local anesthetic levobupivacaine 0.25% was injected. Femoral nerve block was performed with infiltration of 10 ml of levobupivacaine 0.25% perineuraly. Subsequently, 5ml of levobupivacaine 0.25% was injected for the pericapsular nerve group block. Then, the patient were placed in the lateral decubitus position. Posterior lumbar plexus block was performed using anatomical landmarks and peripheral nerve stimulation (Stimuplex® HNS 12, B. Braun, North America), and 10ml of levobupivacaine 0.25% was injected. A total of 35ml of anesthetic was applied for the PNB, afterwhich complete anesthesia of the hip and thigh region was achieved.

PNB achieves adequate conditions for trochanteric fracture surgery, postoperative analgesia, while preserving a hemodynamic stability, which enables early rehabilitation and better recovery after surgery.

Coccygectomy is a treatment of last resort for chronic coccydynia unresponsive to conservative therapy. While general and neuraxial anesthesia are commonly preferred, the Sacral Multifidus Plane Block (SMPB) may provide a safer and more comfortable regional anesthesia alternative. We present two cases where SMPB was used as the primary anesthetic technique for coccygectomy.

Two female patients underwent ultrasound-guided SMPB at the S2–S4 level. With patients in the prone position, under ultrasound guidance, the needle was advanced in a caudocranial direction using an in-plane approach, targeting the fascial plane between the sacrum and the multifidus muscles. A total of 20 mL of 0.5% bupivacaine was administered to this area, targeting the midline to ensure sufficient bilateral spread. Sensory block was assessed every 5 minutes using pinprick testing. After confirming adequate sensory block, sedation during surgery was maintained using dexmedetomidine.

Both patients successfully underwent the surgical procedure with the SMPB as the sole anesthetic technique, without the necessity for conversion to general anesthesia. Case 1: Pain sensation was fully absent by the 10th minute and sensory block covered T12–S3. Transient right leg motor weakness (4/5) and numbness in the right foot were noted. No analgesics were required during or after surgery, with a maximum numeric rating scale (NRS) score of 4 within 24 hours. Case 2: Pain sensation disappeared by the 15th minute and block range was L4–S3. No motor deficits occurred. Intravenous paracetamol (1 g twice daily) was administered postoperatively for pain (max NRS 5). Patients were discharged the next day without complications and reported no analgesic need at one month.

SMPB offers a promising, effective, and safe anesthetic option for coccygectomy, providing reliable analgesia and facilitating recovery. Further research is essential to evaluate its broader applications in pelvic and sacral surgeries.

The interscalene brachial plexus block is a widely used regional anesthesia technique for shoulder and upper arm surgeries. While the unilateral interscalene block is considered safe and effective in most patients, performing this block bilaterally poses significant risks. When applied bilaterally, this can lead to bilateral diaphragmatic paralysis, a potentially life-threatening condition. Additionally, the cumulative local anesthetic dose increases the risk of systemic toxicity.In select, life-threatening airway cases, its use may be reconsidered as a rescue anesthesia technique when general anesthesia is not feasible.

A 41-year-old male sustained a severe mine blast injury resulting in traumatic bilateral upper limb amputations at the upper third of the humerus and a comminuted mandibular fracture. The patient had recently been decannulated following prolonged mechanical ventilation via tracheostomy. Surgical intervention was planned for debridement and suturing of the amputation wounds. Due to the unstable airway (post-tracheostomy, fractured mandible, and distorted facial anatomy), general anesthesia was considered high risk.A bilateral interscalene brachial plexus block was performed under ultrasound guidance using reduced volumes of local anesthetic on each side to minimize the risk of diaphragmatic and systemic complications. The blocks provided adequate surgical anesthesia, and the procedure was completed successfully without adverse respiratory or cardiovascular events.

After intravenous sedation with midazolam, bilateral interscalene brachial plexus blocks were performed under ultrasound guidance. Each side received 10 mL of 0.5% bupivacaine hydrochloride along with intravenous dexamethasone (4 mg). The patient remained hemodynamically stable, with no signs of respiratory distress, phrenic nerve involvement, or local anesthetic toxicity. Surgical wound suturing was completed successfully with excellent anesthetic effect.

This case demonstrates the potential life-saving role of bilateral interscalene brachial plexus block in extreme trauma scenarios with compromised airway anatomy. With appropriate precautions—including ultrasound guidance and careful dosing—bilateral blocks may be considered in select high-risk cases where general anesthesia is contraindicated.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare autoimmune disease which affects the sensory nerves, leading to weakness and sensory symptoms. Few studies have been reported on anesthetic management of this condition, thus our aim is to suggest an appropriate anesthetic plan for the management of a patient with CIDP, undergoing total hip arthroplasty.

A 63-year-old patient with CIPD required a total left hip arthroplasty due to osteonecrosis. A combined plan of general anesthesia and a femoral nerve block were decided on, due to concerns of high post-op pain levels and symptom aggravation. An ultrasound-guided nerve block was performed using 20ml of 0,2% ropivacaine after GA was induced and the patient was intubated.

The patient reported no pain post-op (VAS score 0). Adequate analgesia was achieved thereafter, and no worsening of sensory symptoms during the rehabilitation period was reported.

Due to successful patient outcome, a combination of GA and peripheral nerve blocks may be a suitable option for patients with CIPD and may be considered as an anesthetic plan for patients with this condition.

Limb dislocations are common pathologies requiring emergency treatment. In the United States, 24 shoulder dislocations are reported per year per 100,000 people, or nearly 80,000 dislocations. (1) It most often occurs after a violent trauma. Young adults are most often affected; it is common in epileptics. Reduction of the dislocation is a trauma emergency(2) All types of anesthesia can be used for shoulder dislocation reduction (1). The objective of this study was to evaluate the efficacy and safety of the interscalene block for shoulder dislocation reduction.

Prospective descriptive study conducted in Batna University Hospital during the 2023/2024 . Inclusion criteria were adult patients admitted for shoulder dislocation. The interscalene block was performed under ultrasound guidance. Demographic data, block data (performance time, onset time, LA), success, and complications were recorded.

Twenty patients were included during the study period. The mean age of our patients was 40 years (range, 19-83). Sex: 18 men / 2 women. All patients fasted for more than 6 hours. All blocks were performed using the lateral in plane approach, except for one patient. For the first 6 cases, we used a mixture of lidocaine and bupivacaine, with a volume between 5 and 10 ml For the following 14 patients, we used 2% lidocaine alone with a volume between 5 and 17 ml . For the injection site: We injected 8 times around C5, 10 times between C5 and C6, and 2 times (7 ml) above C5. The block took 1-5 minutes to perform and the block onset time was 1-2 minutes. Only one complication was reported: paresthesias during a two-injection block. Success was 100% with a single attempt in 18 cases

The interscalene block is an effective and safe technique for reducing shoulder dislocation; ultrasound guidance allows for reduced doses and a reduced risk of complications

Myxoid pleiomorphic liposarcoma is a rare type of liposarcoma that is very aggressive in nature. The curative treatment involves wide excision. In elderly patients with multiple comorbidities, there is no adequate time to fully optimize the patient preoperatively. Peripheral nerve block (PNB) provides an alternative choice for patients who are not good candidates for neuraxial or general anesthesia.

An 87 year old male was admitted for wide excision of a likely malignant back mass with split thickness skin grafting. Patient has heart failure, chronic kidney disease, gout, benign prostatic hyperplasia, dementia, and pleural effusion. Patient previously had tuberculosis and COVID. He also underwent a coronary artery bypass. Paient was started on minimal sedation prior to blocking. Ropivacaine 0.25% with epinephrine was given at 20 mL for each block. The anesthetic techniques done were bilateral anterior quadratus lumborum(QL) and right subgluteal sciatic nerve blocks. Sensory block was noted from T4 to L5 dermatomal levels. A decrease of 20% from the baseline blood pressure was also observed. Patient tolerated the procedure well with minimal postoperative pain, and was discharged 3 days after.

Anterior QL block is an interfascial plane block. Ropivacaine may reach the thoracic paravertebral space and the lumbar plexus since the anterior layer of throcalumbar fascia is continuous with the endothoracic fascia and fascia iliaca respectively extending the usual coverage. Since the source of the skin graft will involve the posterior thigh, a subgluteal sciatic nerve block was added. Since the proximity of the subgluteal sciatic nerve to the posterior femoral cutaneous nerve is quite close, it is also expected for the local anesthetic to cover the posterior thigh.

PNB provides a loophole for patients at risk for postoperative morbidity with the traditional techniques. As long as the anatomy is understood, selective blockade is possible without endangering the other organs.

Femoral neck fracture surgery is commonly performed under general or neuraxial anesthesia. However, patients with severe cardiopulmonary comorbidities are at increased risk of anesthesia-related complications. Regional anesthesia combined with sedation offers a safer alternative. Although femoral nerve block (FNB) and lateral femoral cutaneous nerve block (LFCNB) provide effective analgesia, previous studies report the need for supplemental opioids during surgical manipulation. The pericapsular nerve group (PENG) block, targeting articular branches of the femoral, obturator, and accessory obturator nerves, may enhance analgesia. We report a case managed with FNB, LFCNB, and PENG block under sedation, achieving effective anesthesia with minimal opioid use.

A 76-year-old woman with acute exacerbation of heart failure, bronchial asthma, chronic obstructive pulmonary disease (COPD), and vertebral spondylitis underwent internal fixation for a femoral neck fracture. Anesthesia was achieved with dexmedetomidine sedation combined with ultrasound-guided FNB, LFCNB, and PENG block.

No pain was reported during skin incision or femoral manipulation. Mild discomfort during incision of the tensor fasciae latae muscle required a single intravenous administration of 25 μg fentanyl. No further opioid supplementation was needed. Compared to previous reports requiring cumulative fentanyl doses of 50–100 μg, this case demonstrated that opioid requirements could be minimized to a single microdose, reducing the risks of respiratory depression and hemodynamic instability.

The PENG block likely contributed to effective blockade of both femoral and accessory innervation of the proximal femur. Additional blockade of the superior gluteal nerve might have further reduced the need for opioids. Combining peripheral nerve blocks with sedation presents a promising strategy to enhance safety and minimize opioid-related adverse effects during femoral neck fracture surgery in high-risk patients.

We introduced a dedicated regional anaesthesia (RA) block room for upper limb orthopaedic surgery at an ambulatory care hospital in Glasgow, Scotland. This project assessed the block room impact on theatre utilisation, efficiency and resource allocation.

A retrospective review of 17 “pre-block room” and 17 “block room” lists was performed using theatre record data (Centricity Opera). Lists comprising entirely patients receiving surgical local anaesthetic infiltration only were excluded (n=5). Data on block performance was collected prospectively and analysed using Chi squared and students t-test where appropriate.

The proportion of cases utilising the anaesthetist i.e. those requiring regional or general anaesthesia (GA) improved from 46.8% to 65.7% (p <0.001). The proportion of GA cases fell from 73.5% to 11.8%, with a corresponding increase in awake RA cases from 26.5% to 88.2% (p <0.001). Mean list duration increased by 21.6% (306 min to 372 min, p<0.01), while overall proportion of time spent in theatre increased from 72.1% to 77.1% (p<0.05). This was associated with a 42.9% reduction in mean transition time between cases (35 min to 20 min, p <0.001). Mean time from block start to completion was 13 min 51s, with mean time to surgical anaesthesia 27 min 59s. Of 57 awake blocks performed only one patient required unplanned block supplementation.

The introduction of a block room significantly improved anaesthetist utilisation, shifted anaesthetic preference from GA to RA, and enhanced theatre efficiency and utilisation. These results support using a dedicated block room to optimise surgical workflows.

We present the case of an 80-year-old gentleman who underwent successful angioplasty and stenting of the left popliteal artery under regional anaesthesia. This followed a failed attempt under local anaesthesic due to patient factors, namely agitation and difficulty in positioning. The patient’s medical history included peripheral vascular disease with left second toe critical limb ischaemia, cirrhosis secondary to alcoholic liver disease with portal hypertension, coagulopathy, oesophageal varices and new ascites, severe aortic stenosis (peak velocity 4.55m/s, mean gradient 48mmHg, valve area 0.9cm2), pulmonary hypertension and Barrett's oesophagus. Our aim was to safely facilitate surgery through regional techniques, as general anaesthesia was deemed unsafe. Anaesthetic concerns included severe valvular heart disease, decompensated liver disease, current bilateral bronchopneumonia and a left quadriceps contracture making positioning challenging.

A popliteal sciatic block, femoral nerve block, and ilioinguinal and iliohypogastric block were performed. 10ml of 0.25% l-bupivacaine and 5ml of 1% lidocaine were used for each block, giving a total of 30ml 0.25% l-bupivacaine and 15ml 1% lidocaine. Remifentanil was infused intra-operatively at rates of 1-1.7ng/ml and 1mg of midazolam and 20mg of ketamine were administered to facilitate block administration.

The patient remained stable and comfortable throughout the procedure, requiring no haemodynamic support. Supplemental oxygen was administered via a Hudson face mask.

This case highlights the effective use of regional anaesthesia in a patient requiring emergent surgery who was unsuitable for general anaesthesia, emphasising the role this anaesthetic technique can have in facilitating such cases. Regional anaesthesia has increased in popularity in recent decades with the introduction of ultrasound and the development of safer local anaesthetic agents. Multiple studies support the use of regional anaesthesia in endovascular surgery, showing reduced morbidity, a shorter inpatient stay and a possible reduction in mortality. As such, it should be strongly considered, where appropriate, in this often-comorbid patient group.

Inherited Factor XI deficiency, also known as Rosenthal syndrome or Hemophilia C, is a rare disease caused by variants in the FXI gene, resulting in impairment of the intrinsic pathway of blood clotting and increased bleeding during surgery. Although severe deficiency is rare, it has significant anaesthetic implications.

The authors describe the perioperative management of a 80-year-old female patient with severe hereditary Factor XI deficiency proposed for elective total knee arthroplasty. Considering significant hemorrhagic dyscrasia during a previous orthopedic surgery and the patient's hematological status, a multidisciplinary team discussion was conducted, with administration of fresh frozen plasma the day before the procedure. On the day of surgery, intravenous general anaesthesia combined with ultrasound-guided continuous adductor canal block was performed, with bolus administration of ropivacaine 0,75%. Multimodal analgesia incorporated intravenous acetaminophen and metamizole. Hemodynamic monitoring included the placement of an arterial line, along with three wide-bore peripheral intravenous catheters. Additionally, tranexamic acid and fresh frozen plasma were administered during surgery guided by thromboelastogram.

The procedure was uneventful with an estimated blood loss of 200ml, as well as the postoperative recovery, with no hemorrhagic dyscrasia being reported. The patient was successfully discharged ten days after the surgery, with consistently low visual analog scale scores and with no rescue analgesia other than acetaminophen, metamizole, and perineural ropivacaine 0,2%.

Perioperative multidisciplinary management of patients with severe Factor XI deficiency is essential for optimizing the patient's hematological status, choosing anaesthetic techniques with a lower risk of complications, and ensuring clinical monitoring in the postoperative period.

This case report describes the anesthetic management of a child with Congenital insensitivity to pain with anhidrosis (CIPA)undergoing hollow nail internal fixation for a femoral neck fracture. Given the patient’s unique physiological challenges, we used ultrasound guided femoral nerve block and lateral femoral cutaneous nerve block to avoid the risks associated with general anesthesia or neuraxial anesthesia.

A high-frequency linear transducer was positioned parallel and perpendicular to the inguinal ligament, the femoral nerve appeared , using the inplane approach technique, a 22G needle was advanced from lateral to medial, approaching the femoral nerve, 10 mL of 0.5% ropivacaine was administered near the femoral nerve. The transducer was slightly moved laterally in the inguinal region, show the anterior superior iliac spine, the anterior inferior iliac spine, and the iliopsoas muscle. Using the in-plane approach technique, the 22G puncture needle was advanced from medial to lateral aspect of the anterior superior iliac spine and the superficial layer of the iliopsoas muscle. Then 5 mL of 0.5% ropivacaine was injected to block the lateral femoral cutaneous nerve.

This case contributes to the medical literature by demonstrating a safe and effective anesthetic strategy in a pediatric CIPA patient, highlighting the potential of regional anesthesia techniques as a viable alternative to general anesthesia or neuraxial anesthesia in such high-risk cases.

This case report highlights the successful use of ultrasound-guided femoral and lateral femoral cutaneous nerve blocks in a pediatric CIPA patient undergoing femoral neck fracture surgery. This approach offers a safe alternative to general anesthesia, minimizing risks associated with autonomic dysfunction. It provides new insights into anesthetic management for CIPA patients, with benefits such as reduced opioid use and improved hemodynamic stability.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex procedure, associated with significant physiological alterations, postoperative pain and morbidity [1]. While epidural analgesia is recommended in Enhanced Recovery After Surgery protocols [2], its use in CRS-HIPEC can be limited by perioperative coagulopathy, early anticoagulation resumption and compounded hypotensive effects [3]. The erector spinae plane (ESP) block emerges as an alternative, yet no studies describe its continuous use in this setting.

We present the case of a 72-year-old female, ASA III, scheduled for CRS-HIPEC due to appendiceal adenocarcinoma. Her history included permanent atrial fibrillation on anticoagulation, an implantable cardioverter-defibrillator after in-hospital cardiac arrest and prior cerebrovascular accident following orthopedic surgery. A combined anesthetic approach was planned: balanced general anesthesia and continuous bilateral ESP block at T8–T9 under standard ASA monitoring, supplemented with invasive arterial pressure, processed electroencephalography, neuromuscular blockade and urine output monitoring. The block was performed using a catheter-over-needle system, under ultrasoung guidance. An initial bolus of 10 mL ropivacaine 0.2% was administered bilaterally, followed by intraoperative boluses every three hours (totaling 100 mg ropivacaine), complemented with multimodal systemic analgesia.

The patient remained hemodynamically stable, with uneventful extubation. In the post-anesthesia care unit (PACU), fixed intermittent boluses of 10 mL ropivacaine 0.2% were administered via the perineural catheter, ensuring effective pain control without rescue analgesia. Anticoagulation was resumed on postoperative day (POD) 1. On POD 3, administration was transitioned to on-demand boluses, and the catheter was removed on POD 4. PACU stay was uneventful.

This case demonstrates the successful use of the ESP block, a fascial plane technique, to provide both visceral and somatic analgesia in managing severe surgical trauma while mitigating the risks associated with epidural techniques, including epidural hematoma, infection, and hypotension. Additionally, it contributed to reduced opioid use and promoted enhanced postoperative recovery.

Polytraumatized patients with cervical spine and facial injuries pose a challenge to anesthesiologists, especially regarding airway management. In such cases, regional anesthesia can be a safe and effective alternative, minimizing the risks of airway manipulation while preserving spontaneous ventilation.

A 23-year-old male sustained multiple injuries in a motorcycle accident, including cervical spine fractures (C5 and C7) requiring immobilization, a subcondylar mandibular fracture, and bilateral forearm fractures. Five days after admission, he underwent bilateral internal fixation of the forearms. He was classified as ASA II due to smoking and had preoperative anemia (Hb 7.8 g/dL). Anesthesia was provided via bilateral ultrasound-guided infraclavicular brachial plexus blocks. The toxic dose of local anesthetics was calculated according to his weight (80kg with a normal BMI). A mixture of 10 ml of ropivacaine 0.5% and 10 ml of mepivacaine 1% was used for each block.

The first block was performed on the left, where both radius and ulna were fractured (Figure 1). After 2.5 hours, the right-sided block was performed for distal radius fixation (Figure 2), completed in 1 hour. Surgical anesthesia was achieved without sedation. On the following day, motor block had completely reversed.

This case demonstrates the value of regional anesthesia in a patient with a potentially difficult airway due to cervical spine instability and mandibular fracture. It was possible to achieve great surgical anesthesia, safely, without the need to perform general anesthesia.

Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against postsynaptic acetylcholine receptors. It is characterized by muscle weakness and fatigability, and patients are at high risk of respiratory failure during anesthesia. We present a 69-year-old male patient with a history of diabetes, hyperlipidemia and coronary artery disease, who had a myocardial infarction six months ago and has been diagnosed with myasthenia gravis for 19 years. The patient presented with ptosis in the left eyelid, muscle weakness in both upper and lower left extremities, and an inability to walk. His medications included pyridostigmine, empagliflozin, acetylsalicylic acid, and atorvastatin. Due to an acute calculous cholecystitis episode accompanied by elevated CRP and leukocytosis, a percutaneous cholecystostomy drain was planned by interventional radiology, and anterior QLB was administered for analgesia.

The patient was placed in the left lateral decubitus position, and under ultrasound guidance with low frequency curve probe, a 12 cm needle was inserted between the quadratus lumborum and psoas major muscles. After saline injection we confirm the neddle placement and 20 cc of 0.25% bupivacaine was administered.

Ten minutes after the block, a pinprick test confirmed the absence of pain sensation between the T4 and T10 dermatomes. Visuel analouge scale was under 4 during procedure. The patient remained hemodynamically stable during the procedure (heart rate: 80 bpm, blood pressure: 131/73 mmHg, SpO₂: 97%), with no need for additional analgesia or sedation.

The anterior quadratus lumborum block provides broad dermatomal analgesia through cephalad spread and may also be effective for visceral pain due to its proximity to the rami communicantes. For patients with myasthenia gravis undergoing interventional cholecystostomy, an anterior quadratus lumborum block provides a safer and more selective analgesic alternative, as it prevents the risk of respiratory failure.

Lower back pain is quite common in the Philippines. In 2014,35% of the occupational diseases reported involved back pain[1]. Lumbar spine surgeries are advised and performed to alleviate this problem. Unfortunately, the pain up to three days after the surgery is relatively intense[2]. Performance of regional anesthesia would greatly help to resolve the pain avoiding side effects secondary to opioids.

This paper presents three cases where patients underwent lumbar spine surgeries. Thoracolumbar interfascial plane(TLIP) block was executed after intubation. A volume of 15 ml Isobaric Bupivacaine0.25% was injected between the multifidus and longissimus muscles, and another 5 mL was injected superficial to the posterior thoracolumbar fascia both containing 1:400,000Epinephrine. All patients were given Paracetamol and Ketorolac for 24hours, and shifted to oral pain medications thereafter. A rescue dose of Tramadol 50mg IV every six hours may be given should the VAS score be above 5/10. Two of the patients had a VAS score 0-1 and were able to ambulate within 24 hours. They were discharged on the second postoperative day. These patients didn't require any additional opioid. The third patient, however, required three rescue doses to relieve his pain from a VAS score 5-8 to 2 within the first 24 hours. This can be attributed to the more extensive fusion procedure. The patient was able to ambulate on the second postoperative day and was discharged the next day.

TLIP blocks the dorsal rami of the thoracolumbar nerves without affecting the ventral rami and it does not cause motor block[3]. It can provide analgesia decreasing the need for opioids leading to lesser side effects. It also enables the patient to ambulate early resulting in shorter length of hospital stay.

TLIP is a promising technique for analgesia after spine surgery, offering effective pain relief which potentially alleviates the complications secondary to opioids.

Anterior cruciate ligament (ACL) reconstruction on an outpatient basis requires adequate postoperative analgesic management for timely discharge home and to prevent readmission. The trend toward more distal, motor-sparing nerve blocks led to a change from femoral nerve block (FNB) to femoral triangle block (FTB). This retrospective analysis reports on the quality of postoperative analgesia provided by the FTB compared to the traditional FNB after ACL reconstruction.

Twenty-seven FNB and 18 FTB patients undergoing ACL repair were retrieved between January 2025 and May 2025. As per institutional protocol, patients received paracetamol, NSAIDs, dexamethasone, and LIA (20 ml of bupivacaine 0,5% with adrenaline). In the post-anesthesia care unit, pain was assessed using a numeric rating scale (NRS), and tramadol was administered as rescue analgesia based on breakthrough pain (NRS>4). At discharge, patients were prescribed scheduled paracetamol and NSAIDs (diclofenac), with tramadol 50mg sublingual as a rescue analgesic. Patients were contacted on postoperative day 1 to evaluate the analgesic quality and patient satisfaction.

Demographics were similar in both groups. NRS pain scores in the post-anesthesia care unit (PACU) were 4.9 on average in patients receiving FTB and 3.7 for FNB (p = 0.10). One FTB patient required a postoperative FNB rescue block. On postoperative day 1, no significant difference was observed in NRS scores, opioid consumption, and qualitative outcomes such as satisfaction of analgesia, sleepless nights, first food intake, and mobility. However, motor loss was more prevalent in patients receiving FNB (<0.05).

Lower PACU pain scores in patients receiving FNB compared to FTB could suggest higher analgesic potency of the FNB in patients receiving ACL reconstruction, especially since pain scores on postoperative day 1 were comparable. However, results were not significant and FNB was associated with more motor loss.

Concomitant aortic stenosis (AS) in fragility fracture patients, makes anesthesia management challenging, and amplifies surgical risks by causing left ventricular dysfunction and reducing coronary artery perfusion, leading to 30-day mortality rates that are 2-3x greater compared to non-AS patients. This case report details the successful use of a combined psoas compartment and parasacral sciatic nerve block in an elderly Filipino patient with severe AS undergoing proximal femoral nailing.

We report a case of a 75-year-old Filipino woman with severe AS, metabolic syndrome, and anemia, who sustained a fragility hip fracture with subtrochanteric extension, who underwent proximal femoral nailing. Her complex profile—ASA class 3, Revised Cardiac Risk Index intermediate risk (6.0%), and chronic conditions—underscored the need for hemodynamically stable anesthesia. A combined ultrasound-guided psoas compartment and parasacral sciatic nerve block with 20 mL ropivacaine 0.5% each was employed to circumvent risks of general anesthesia (myocardial depression, hypotension) and neuraxial techniques (sympathetic blockade). The psoas block targeted lumbar plexus for anterior/lateral coverage, while the parasacral block anesthetized sciatic nerves for posterior pain control. Sedation and anxiolysis were achieved using remifentanil (TCI minto model 0.5–0.8 ng/mL) and dexmedetomidine (0.4–0.6 mcg/kg/hr).

Intraoperative hemodynamics remained stable throughout the surgery (SBP 120–130 mmHg, HR 70s). Postoperative pain (NRS 0/10) was adequately controlled with oral paracetamol and cox-2 inhibitor.

This case underscores combined psoas compartment block and parasacral sciatic nerve block as an effective strategy for managing frail patients whose condition requires avoidance of sharp fluctuations in the patient’s hemodynamics. By optimizing analgesia while mitigating cardiovascular risks, enhance perioperative safety, advocating for the techniques broader adoption in fragility fracture surgery.

Pain management in clavicle surgery is challenging due to its complex innervation. The interscalene brachial plexus block has been traditionally used but carries risks such as phrenic nerve paralysis. The combined clavipectoral fascia (CPB) and superficial cervical plexus block (SCPB) has emerged as an alternative technique that may provide effective analgesia without impairing respiratory function. This study evaluates the efficacy and safety of CPB-SCPB in midshaft clavicle surgery. Ultrasound images of CPB and SCPB are attached.

A case series study was conducted in seven patients (six men, one woman, mean age 48.6 ± 15.6 years) undergoing surgery with CPB-SCPB. Pain levels were assessed using the VAS scale in the immediate postoperative period and at 24 hours, as well as the need for rescue analgesia and conversion to general anesthesia.

VAS score 0 was observed in 85.7% of patients immediately postoperatively, and at 24 hours, all had VAS < 4. Only one patient required rescue analgesia (metamizole at 18 hours). No opioids were used. Two patients (28.6%) required conversion to general anesthesia. One minor complication (transient paresthesia in the neck and cheek) was recorded. Two patients were discharged as outpatient.

CPB-SCPB provides effective analgesia in clavicle surgery, reducing opioid use and facilitating early discharge. Its safety profile suggests it is a viable alternative to the interscalene block. Controlled studies are needed to confirm these findings.

Patients with hematological malignancies are immunocompromised and susceptible to soft tissue and bone infections, which may require multiple surgical debridement procedures. Thrombocytopenia and anaemia associated with hematological diseases require special consideration in anaesthesia planning and management. Regional anaesthesia offers an alternative to general anaesthesia, especially in high-risk patients.

A 61-year-old male patient with chronic myelomonocytic leukemia, thrombocytopenia and osteomyelitis was referred to our institution for surgical management of a secerning fistula in the posterolateral right femur. The sequestrectomy with necrosectomy was performed under general anaesthesia with adjunct sciatic nerve block. The patient underwent seven subsequent necrectomies, two of which were in sciatic and lateral femoral cutaneous nerve block, while the remaining five were under general anesthesia, by different anaesthesiologists.

Procedures done under regional anaesthesia were opioid-free, with postoperative pain scores 2/10 on the numerical rating scale, compared to 5–7/10 after general anaesthesia. Patient exhibited more stable intraoperative hemodynamics and required fewer postoperative analgesics when the necrosectomy was performed under peripheral nerve block.

Peripheral nerve blocks performed in an aseptic technique may present a safe and effective alternative to general anaesthesia in immunocompromised patients requiring repeated surgical debridement. Special consideration is required when planning anesthesia or analgesia involving deep peripheral nerve blocks in patients with moderate to severe thrombocytopenia.

Abdominal wall blocks (AWB) are increasingly used as part of multimodal analgesia, offering a safer, simpler alternative to neuraxial techniques (1,2). Blocks such as transversus abdominis plane (TAP), quadratus lumborum (QL), ilioinguinal/iliohypogastric (II/IH), and rectus sheath (RS) have shown varied effectiveness depending on surgery type (3–5).

Retrospective descriptive study conducted at a tertiary center, including 102 patients, aged ≥18 years, who underwent abdominal surgery with an AWB between January 2023 and December 2024. Data were obtained from electronic medical records and included demographics, ASA status, surgical specialty, urgency, block type, and anesthetic details. Outcomes assessed were postoperative pain, opioid use, rescue analgesia, and complications within 72 hours.

In two years, 102 patients underwent abdominal surgery with an AWB. Most were female (72.5%) with a mean age of 59. ASA II and III predominated (56.4% and 30.4%). Surgeries were mainly elective (67.6%), across general surgery (49%), gynecology (41.2%), urology (3.9%), and obstetrics (5.9%). Blocks performed included TAP (57.8%), QL (34.3%), II/IH (3.9%), and RS (3.9%), using ropivacaine (0.2–0.75%), mean 125 ± 33 mg. Mean pain score was 1.78 ± 1.57. Within 24h, 26.4% required opioid rescue. No short-term complications were observed.

AWB proved to be safe and effective for postoperative analgesia in abdominal surgeries, with low pain scores, modest opioid use, and no short-term complications. These results support their role as reliable alternatives or adjuncts to neuraxial techniques, especially within multimodal and enhanced recovery protocols.

Laparoscopic cholecystectomy is associated with significant pain after surgery and is one of the most common causes of readmission after ambulatory laparoscopic cholecystectomy. The external oblique intercostal (EOI) block is a more recently described regional anesthesia approach to anesthetize the upper abdomen which is easy to perform and may provide effective analgesia for laparoscopic cholecystectomy.

We report of three cases aim to describe the use of the EOI block in providing analgesia following laparoscopic cholecystectomy. After induction of general anesthesia, the EOI block was performed using an ultrasound-guided in-plane approach. Local anesthetic was injected between the fascial plane of the external oblique muscle and the external intercostal muscle at the level of the intercostal space between the 6th and 7th rib.

Three female patients, aged 62 to 71 years, underwent laparoscopic cholecystectomy under general anesthesia with an EOI block. None of the patients required opioids for intraoperative analgesia beyond induction. Postoperatively, all three patients reported only mild-to-moderate pain localized to the umbilical port site. Postoperative opioid consumption was minimal. No adverse effects or block-related complications were observed.

In conclusion, the EOI block is effective for analgesia in laparoscopic cholecystectomy and should be considered in routine peri-operative strategies. Further research may explore its role in other laparoscopic upper abdominal surgeries and compare its efficacy with blocks offering sympathetic visceral coverage, such as the ESP or paravertebral blocks. Cadaveric studies may also help clarify its anatomical basis for such coverage.

Effective pain management is crucial for patients with lower limb trauma in the remote Scottish Highlands, where long transport times to hospital are common. The Highland Pre-Hospital Immediate Care and Trauma (PICT) Team is trained to place lower limb nerve blocks (LLNBs) at the scene of injury, enabling earlier and more effective analgesia. This review assessed the safety and effectiveness of pre-hospital LLNBs performed by PICT from 2019 to 2023.

During this period, a total of 96 patients received LLNBs. Data collected included block type, use of ultrasound, documentation of pain scores, and complications.

Of the 96 LLNBs, 72 were fascia-iliaca blocks (FIBs), 19 were femoral nerve blocks, and in 5 cases the block placed was unclear. Ultrasound guidance was utilised in 17 cases, a landmark approach employed in 16 cases, and documentation was incomplete in the remaining 63 cases. Pain score documentation varied widely: pre-LLNB, 6 patients had quantitative scores and 17 qualitative scores documented; post-LLNB, 2 had quantitative scores and 36 qualitative scores documented. No adverse events were reported.

Whilst LLNBs are seen as a safe technique, documentation quality was inconsistent, limiting the ability to assess their clinical effectiveness in managing pain from lower limb trauma. From this review a standardised document for LLNBs has been developed (see Table 1), based on local and national best practices, aiming to improve data capture and support future service evaluations.

Regional anesthesia is increasingly recognized as a valuable option for high-risk patients undergoing hip surgery. Fascial plane blocks, particularly lumbar and sacral erector spinae plane (ESP) blocks, offer promising hemodynamic stability. We present a single high-risk cardiac patient undergoing hemiarthroplasty who was successfully managed using a novel dynamic needling technique for sacral and lumbar ESP blocks. This approach aims to optimize anesthetic spread while minimizing volume and potential systemic toxicity.

An 87-year-old male with severe aortic stenosis, NYHA Class III heart failure, and multiple comorbidities was scheduled for hip hemiarthroplasty. To avoid general and neuraxial anesthesia, we performed a femoral nerve block, sacral ESP block at S2, and a lumbar ESP block at L2 using ultrasound guidance. Crucially, both ESP blocks were executed using a dynamic needling technique: the needle was actively repositioned within the fascial plane during injection to ensure optimal spread while carefully titrating the volume of local anesthetic.

A total of 35 ml of 0.375% ropivacaine was used across all blocks. The dynamic technique allowed termination of injection upon achieving target dermatomal coverage (T12–S3), reducing unnecessary volume. The patient underwent surgery under light sedation with spontaneous breathing and remained hemodynamically stable throughout. No opioids or vasopressors were required intra- or postoperatively.

This case highlights the potential of dynamic needling in fascial plane blocks to optimize anesthetic spread while minimizing volume and reducing the risk of local anesthetic systemic toxicity (LAST). In high-risk patients, this technique may represent a valuable and safer alternative to conventional regional anesthesia approaches. Further studies are warranted to validate its efficacy and reproducibility.

We present a case of a 73-year-old gentleman with a displaced scapular spine fracture originating from the superior screw of a reverse total shoulder arthroplasty performed three months earlier. To help with perioperative pain, we used a dual regional anesthesia technique consisting of a thoracic paravertebral block and an anterior suprascapular nerve block to optimize analgesia. Before performing the paravertebral block, we used a small, curvilinear ultrasound probe identified the T2 and T3 spinous and transverse processes. A 22Gx8cm Tuohy needle was inserted, aiming to contact the transverse process. After doing so, the needle was withdrawn to the subcutaneous tissue, redirected more caudad, and advanced 1 cm beyond the depth of the transverse process to enter the paravertebral space. 6 mL of 0.5% ropivacaine was deposited at each level (T2/T3 and T3/T4). The suprascapular nerve block was performed using a linear ultrasound probe (5-14MHz). From the supraclavicular nerve block anatomy, the suprascapular nerve was identified as the most lateral branch of the upper trunk, exiting laterally and posteriorly under the omohyoid muscle to enter the shoulder joint. Under ultrasound guidance and nerve stimulation, a 22Gx5cm insulated needle was inserted in-plane, from lateral to medial, and 10 mL of 0.5% ropivacaine was deposited near the suprascapular nerve, avoiding adjacent vessels. The blocks provided immediate pain relief, with the patient’s pain score decreasing from 8/10 to 2/10—this improved range of motion in his shoulder without causing total motor weakness. The case proceeded under general anesthesia, requiring no additional narcotics intraoperatively or postoperatively.

The paravertebral block offers segmental coverage of thoracic spinal nerves, addressing somatic and sympathetic pain pathways. The suprascapular nerve block targets the supraspinatus and infraspinatus muscles and a significant portion of the scapular periosteum without causing significant motor weakness. This multimodal approach ensured adequate intraoperative anesthesia and postoperative analgesia.

Regional anesthesia is preferred alone or in combination with general anesthesia for shoulder surgery due to its advantages, including hemodynamic stability, effective postoperative analgesia and avoidance of airway manipulation. Our patient had a history of recurrent tracheotomy and free flap reconstruction of the right neck and cheek(Figure1), which significantly altered the anatomical structure, rendering interscalene block (ISB) unfeasible. Therefore, a combination of supraclavicular brachial plexus block (SCBPB), suprascapular nerve block (SSB), axillary nerve block (ANB) and serratus posterior superior intercostal plane block (SPSIPB) was selected.

CASE REPORT/Methods A 50-year-old male, scheduled for metastatic mass resection from the right acromion, had a history of malignant buccal mucosa tumors, mandibulectomy, extensive neck dissection, and free flap reconstruction. Previous surgeries required tracheotomies, which were later decannulated before discharge. A total of 200 mg of bupivacaine was used under ultrasound guidance: SCBPB, SSB, ANB , and SPSIPB (table1)(figure2). Sedation was provided using dexmedetomidine. The 150-minute surgery proceeded without additional analgesics (figure3). Postoperatively, the highest NRS pain score was 3, with no opioid need over 36 hours.

ISB was contraindicated due to anatomical disruption. SCBPB alone may not ensure complete anesthesia; thus, SSB and ANB were added. SPSIPB is a newly described block. Fascial plane blocks may be preferred to expand the dermatomal block area in regions with multiple dermatomal innervations. To provide anesthesia for the relevant surgical area, a thorough understanding of dermatomal, myotomal, and osteotomal innervations is required. This knowledge enables the creation of block combinations that effectively cover the targeted region.

Rib fractures are associated with significant mortality and morbidity secondary to pain induced hypoventilation which is often exacerbated by opioid use. In elderly patients, each rib fracture increases pneumonia risk by 27% and mortality by 19%. In light of recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance against the use of modified-release opioids for post-operative pain due to the associated risk of opioid-related complications, the use of opioid-sparing techniques has become imperative. Regional anaesthesia offers a promising alternative but is underutilised. This study aims to assess rib fracture pain management at Wythenshawe Hospital and implement a structured pain management pathway promoting the early use of erector spinae plane (ESP) block catheters.

We retrospectively reviewed patients with radiologically confirmed rib fractures at Wythenshawe Hospital between 1st September 2024 and 17th March 2025. Data included patient demographics, STUMBL (STUdy of the Management of BLunt chest wall trauma) scores (calculated retrospectively), analgesic plans, 72-hour oral morphine equivalent (OME) consumption, and the use of regional techniques.

106 patients were identified with a median age of 69. No STUMBL scores were recorded, and retrospective scoring showed 39% were at high risk of complications. 21 patients required admission and none received regional analgesia. Nearly all patients were managed with opioids, with a median 72-hour OME of 44 mg.

This study identified the underutilisation of regional anaesthesia and formal risk stratification in the management of rib fractures. Higher STUMBL scores are associated with an increased risk of complications with scores of 11–15 associated with 29% probability of complications, whilst scores exceeding 30 indicate an 88% risk. In response, we have implemented a trust-wide pathway, integrating early use (within 24 hours) of ESP block catheters for patients with a STUMBL score >10. A follow-up audit is underway to assess implementation uptake and its effect on opioid consumption.

A 53-year-old man presented with infected diabetic foot ulcer, dyspnea, weakness, and hyperglycemia. His foot ulcer had worsened prompting above-knee amputation. His medical history included: dextrocardia, uncontrolled diabetes, ischemic heart disease, heart failure, severe pulmonary hypertension, heart block with malfunctioning pacemaker, and chronic kidney disease. Preoperative assessment revealed hypoxia (SpO₂ 88%), pulmonary congestion, and echocardiographic findings of dextro-transposition of the great arteries (d-TGA) with an atrial septal defect. This case underscores the anesthetic challenges in managing uncorrected congenital heart disease with multi-organ dysfunction during non-cardiac surgery, emphasizing hemodynamic optimization and perioperative risk mitigation. Given the high mortality of uncorrected TGA, reports on regional anesthesia for non-cardiac surgeries are limited.

Retrospective data collection from January 2025 – February 2025. Detailed history taking was done three times alongside referral to the available electronic medical records.

Ultrasound-guided peripheral nerve blocks (PNBs) with 0.375% ropivacaine targeted the femoral (15 mL), lateral femoral cutaneous (10 mL), and subgluteal sciatic nerves (25 mL), sparing the obturator nerve. During the operation, the patient did not require further analgesics or a rescue block. Hemodynamics remained stable without the need for inotropic or vasopressor support.

PNBs are generally safe in cardiac patients but require dose adjustments in complex congenital heart disease to avoid systemic toxicity. For above-knee amputation, precise local anesthetic dosing is crucial due to the variable knee innervation. Despite risks like Local Anesthetic Systemic Toxicity (LAST) and nerve injury, meticulous planning—balancing pulmonary and systemic vascular resistances (PVR and SVR), normothermia, and anesthetic choice—enables safe anesthesia in high-risk cases like unrepaired TGA.

Peripheral regional techniques, such as femoral nerve block or fascia iliaca block, are widely used to complement subarachnoid anesthesia in hip fracture surgery. However, local infection or anatomical constraints may contraindicate these approaches. The lumbar plexus block (LPB) offers an alternative pathway for analgesia while avoiding compromised areas. We present a case where LPB was successfully employed in a high-risk patient with an inguinal infection, highlighting its role as a viable option in complex scenarios.

An 87-year-old female with cardiac insufficiency (NYHA II/IV), atrial fibrillation, hypertension, obesity (grade 1), and chronic kidney disease (G3bA2) was proposed for intramedullary nailing of a subtrochanteric femoral fracture. Due to a contraindicating inguinal cutaneous infection, femoral/fascia iliaca blocks were deemed unsafe. Instead, a Shamrock technique LPB was performed under combined ultrasound and neurostimulation guidance, using a 100mm needle and 20 mL of 0.2% ropivacaine. A subarachnoid block (9mg bupivacaine + 0.002mg sufentanil at L2-L3) was then performed as the primary anesthetic.

The combined lumbar plexus and subarachnoid blocks provided adequate surgical anesthesia without complications. Surgery proceeded uneventfully, and postoperative pain was managed with paracetamol 1g and tramadol 50mg. The patient reported satisfactory pain control throughout recovery and was discharged on postoperative day 4.

When inguinal infection contraindicates femoral or fascia iliaca blocks, LBP can be a safe and effective alternative when performed with proper imaging and neurostimulation. This case underscores that LPB can be integrated into multimodal analgesia strategies in selected patients, offering reliable pain relief while minimizing infection risks.

Acetabular fractures, often resulting from high-velocity trauma, present challenges for administering neuraxial anaesthesia due to coexisting injuries, suboptimal positioning, or coagulopathy. This case study explores the feasibility and analgesic efficacy of continuous ultrasound-guided (USG) lumbar erector spinae plane block (ESPB) in such cases.

Five patients (3 males, 2 females; median age 55 years; ASA II–III) underwent posterior acetabular fracture repair by posterior approach under general anaesthesia. Subsequent to induction of general anaesthesia , USG guided continuous Lumbar ESPB was placed at L4 transverse process using a curvilinear probe and 100 mm 18G Contiplex S Ultra 360 ,a catheter through needle system(B-Braun Medical). Following placing catheter, 20 ml of 0.375% Inj Ropivacaine was administered in all the cases. Post-operatively, 20ml of 0.2% of Inj ropivacaine was administered 8 hourly daily through the catheter for three days, along with IV Inj paracetamol 8 hourly. Pain was assessed using the Numerical Rating Scale (NRS); IV fentanyl was planned for rescue analgesia.

Median NRS scores were 1(static) at rest and 3 on movement(dynamic). None of the patients required opioid rescue. Hemodynamic parameters remained stable throughout, and no complications related to the block were observed.

Continuous lumbar ESPB as an integral component of multimodal analgesia has the potential to reduces pain scores, minimise opioid use, and preserving motor function in patients undergoing acetabular fracture repair by the posterior approach. Further validation in larger randomized trials is recommended.

In 2020 we initiated a prospective cohort study on the application of posterior quadratus lumborum block (QLB) in patients with chronic hip pain. Subsequently, an attempt was made to identify local anaesthetic diffusion with ultrasound.

Blocks were performed with the patient in the lateral decubitus position on the healthy hip. A medial to lateral approach was made placing 20ml of local anaesthetic in the fascial space at the posterior aspect of the quadratus lumborum muscle. (Figure 1). We observed a different distribution of sensitivity in patients receiving the posterior QLB , an hypoaesthesia in the lower-lateral side of the abdomen, posterior thorax or towards the lumbar and gluteal region. We wondered whether it would be possible to perform an ultrasound scan of the diffusion of the local anaesthetic along the fascial plane.For this purpose, the patients were kept in lateral position after the block and a scan was performed at 15 and 30 minutes later.we added the local anaesthetic diffusion values on the data collection sheet.

The results of the 30 patients evaluated showed anterior diffusion in 60% (18/29) and posterior diffusion in 40% (12/30). Figure 2 and 3. These diffusions coincided with the distribution of hypoaesthesias shown by the patients. 15 patients showed a caudal diffusion, coinciding with the clinical hypoaesthesia in the upper gluteal region (cluneal nerve block), 7 of them had also shown a cephalic diffusion up to rib 12. With regard to the clinical implications of these findings, we found that those patients with the greatest improvement coincided with anterior diffusion.

Our results show that it is possible to assess local anaesthetic diffusion. Although most of the patients who showed improvement had anterior diffusion, we cannot conclude that the mechanism in the control of chronic hip pain is the block of anterior branches of lumbar plexus.

Sciatic nerve catheter is known to improve perioperative pain compared with single shot sciatic block. With healthcare cost increasing exponentially worldwide, we aim to analyze the cost effectiveness of sciatic nerve catheter compared with single shot sciatic nerve block for patients requiring repeated surgical interventions.

In this pilot study, we analyzed the anesthesia cost of two hypothetical patients in Ng Teng Fong General Hospital, who had sciatic nerve catheter inserted as the sole anesthesia for surgical procedure. These patients had surgical wounds only in the distribution of sciatic nerve and were expected to require repeated surgeries. The anesthesia cost was calculated based on local hospital cost framework.

Patient 1 had sciatic nerve catheter inserted during first surgery and for pain management. Patient 1 subsequently had two more wound debridement which anesthesia was provided through top up of sciatic nerve catheter. The total anesthesia cost for three procedures performed under sciatic nerve catheter top up was USD442.96. If patient 1 had received three single shot sciatic nerve block, the total anesthesia cost would be USD599.99, which was 35.4% more expensive than using sciatic nerve catheter top up. Patient 2 had sciatic nerve catheter inserted during first surgery and had catheter top up for a subsequent procedure. His total anesthesia cost for the two procedures under sciatic nerve catheter top up was USD419.60. If Patient 2 had received two single shot sciatic nerve block for these two procedures, the total anesthesia cost would be USD399.99, which was 4.7% cheaper than performing anesthesia under sciatic nerve catheter top up.

Sciatic nerve catheter provide good cost-effectiveness for patients requiring more than one surgical procedure. Even if only one additional procedure was performed with catheter in-situ, the total anesthesia cost was only slightly more expensive than if two single shot sciatic nerve block was performed.

Peripheral nerve blocks are a cornerstone of modern anaesthesia, offering superior perioperative analgesia. However, once patients leave the hospital, the window for clinical review closes. Post-discharge follow-up is often inconsistent, limiting our ability to easily follow-up on our patients in a time-efficient manner. With the widespread implementation of the EPIC/Encompass electronic health record across our Trust, I found an an opportunity to modernise our follow-up processes and close this gap. My aim was to develop and implement a digital follow-up system using the EPIC/Encompass platform to monitor patients at home post peripheral nerve block. It will allow anaesthetisiologists to collect data on block offset times, pain trajectories, patient satisfaction, and complications, enabling the enhancement of care, audit outcomes, and contribute to long-term quality improvement.

Methodology included reviewing existing pathways in place in other trusts; which were limited. Creation of a patient questionnaire to assess block wear off as well as pain scores and patient satisfaction. This was then integrated into the patient care system (EPIC/Encompass) which automatically sends the questionnaire to the patients mobile telephone application for completion.

Successful creation of a patient follow-up questionnaire with the system going live in July 2025 for use in the Belfast Health & Social Care Trust, enabling us to detect nerve injury early and optimise patient care. The results of our pilot will aim to show early detection of nerve injury (if any) and also provide data on block wear-off, pain scores and patient satisfaction for audit.

Integrating patient follow-up for peripheral nerve blocks into the EPIC/Encompass platform is a feasible and innovative approach to improving patient care. It enables real-time data collection on block outcomes, enhances patient safety, and supports ongoing audit and quality improvement. This digital pathway bridges the gap between theatre and recovery at home—bringing follow-up into the 21st century.

Paravertebral block (PVB) achieves anesthesia by injecting local anesthetic beneath the superior costotransverse ligament (SCTL), targeting the anterior ramus of the spinal nerve. Although PVB typically affects multiple thoracic levels, the mechanism underlying this spread remains controversial. It is often attributed to a "paravertebral space," yet no anatomically distinct space has been definitively described. This study aimed to determine the actual anatomical route responsible for local anesthetic spread during PVB.

Two embalmed cadavers were dissected through the internal thoracic wall. At the 7th intercostal space, the neurovascular bundle was identified between the anterior and posterior components of the SCTL. After careful removal of the intercostal artery and vein, the spinal nerve located beneath the superior rib was exposed. Methylene blue dye was injected using a paravertebral approach at the 6th intercostal space. The spread of the dye was subsequently evaluated by dissection, focusing on its course through the intervertebral foramen and adjacent structures.

In both cadavers, the dye extended from the medial aspect of the spinal ganglion toward the spinal nerve, indicating spread from the epidural space. In the first specimen, surrounding connective and adipose tissue were removed to reveal the spinal ganglion and rami communicantes. Dye distribution filled the intercostal groove from medial to distal. In the second specimen, the posterior SCTL was broader, and the anterior component again covered the ganglion; the dye followed a similar path.

Although anatomically there is no true paravertebral space, this study demonstrated that multi-segmental—and occasionally contralateral—spread may occur via lateral extension of the epidural space beneath the SCTL. The presumed wedge-shaped paravertebral space appears not to be cranio-caudal but instead represents segmental projections of the epidural space. Larger cadaveric studies are warranted to validate these findings.

High-energy polytrauma patients with rib fractures, pleural effusion, and multiple orthopedic injuries face dual challenges: respiratory compromise risks from general anesthesia and thromboembolic complications from prolonged immobilization. This case underscores the role and safety of regional anesthesia in solving perioperative challenges between the surgical urgency and duration versus patients acute conditions.

A 55-year-old male, victim of a high-kinetic vehicle accident, presented with acetabular/forearm/9th rib fractures, pleural effusion, right lower lobe atelectasis, and perirenal hematoma. Ultrasound-guided regional anesthesia included a fascia iliaca, obturator, and subgluteal sciatic blocks for acetabular fixation combined with subdural anesthesia and an axillary block for forearm fracture repair. Light propofol sedation maintained spontaneous ventilation during 6-hour surgery.

Hemodynamic stability was achieved without vasopressors and mechanical ventilation was avoided, a critical problem given the thoracic injuries. Regional techniques provided optimal postoperative analgesia, enabling ambulation by day 4 and discharge on day 6 – key factors in reducing immobilization-related complications. The case illustrates two evidence-based advantages: mechanical ventilation avoidance preserving respiratory function in pleural effusion/atelectasis and early surgery timing minimizing thromboembolic risks without exacerbating hematoma expansion.

Comprehensive regional anesthesia enables complex polytrauma management in non-intensive care settings, resolving critical challenges between surgical timing, bleeding risks, and thrombosis prevention. This approach proved to be safe and effective in resource-limited environments while providing an enhanced recovery.

Regional Anaesthesia(RA)-nerve blocks+GA are usually performed for breast cancer surgery. But whenever patient’s medical condition dose not permit (1, 2, 3), nerve blocks become a boon and favourable oncological outcome of pain management in comparisons to volatile anaesthesia+opioid.

76 year,female patient with ASA risk III (Height – 153 cm, weight -69kg), having Invasive Ductal breast carcinoma (T2N0M0) of left breast posted for Simple Mastectomy and lymph node sampling. She is C/o Severe Advanced Interstitial Lung disease with fibrosis Emphysematous chest, Hypertension, Heart failure, DM. She is on steroids+ home oxygen with desaturations with Spo2 88-90% and Severe Pulmonary hypertension with RSVP- 82mmofHg. Severe Reduction in DLCO. 6Minite Walking Test- Desaturation 76% (4 min). She is high risk for pulmonary complications from Positive Airway Pressure ventilation and GA with extreme care, if unavoidable/lifesaving surgery for barotrauma, volu-trauma. The patient had requested to RA with nerve blocks (Paravertebral + pectoral nerve blocks or thoracic epidural) with sedation. Informed Consent and MRC approval was obtained. All monitoring and Aseptic precautions, Ultrasound(US) guided Thoracic Paravertebral block (PVB) (Fig.1) was performed in sitting position at T3, T5, and T7 level with Curvilinear probe and identified triangular PVB (Picture.1)with Lidocaine+adrenaline(1:200,000) 3ml + 0.33%levobupivacaine 7 ml at each level after negative aspiration, pleura was pushed down. Pectoral blocks (Pic. 2) were performed between the Pec minor and serratus at 4th rib and between Pec Major and minor with 5 ml of 2%lignocaine +adrenaline + 0.33%Levobupivacaine 3 ml each. SSurgery was started after confirming the block effect. Sedation with Fentanyl 100 mcg+TCI Propofol of 0.5-1 mcg/ml. Surgical Duration was 1 hr 40min. Patient was very comfortable during operation and postoperatively(NRS >3).

Whenever a medical condition of the patient cannot allow for GA, Multiple level nerve blocks can be a boon and act as rescue when expertise available.

Providing analgesia for the knee is challenging due to complex innervation arising from different nerves. We describe a novel ultrasound-guided fascial plane block technique for analgesia of the knee. The novel method was used in patients suffering from knee osteoarthritis.

This report presents a description of the Anterior Nerves of the Knee (ANK) block and application to 28 patients diagnosed with Grade 4 Kellgren-Lawrence knee osteoarthritis (KOA) with severe pain. The study was approved by the institutional Ethics Committee (E-71522473-050.04-340179-38) . The ANK block was performed by a single injection of local anesthetic within the fascial plane between the rectus femoris and vastus muscles (Figure 1). Bupivacaine 0.25% 20 ml was injected. The pain charts of the patients were reviewed and numerical rating pain scores (NRS) were evaluated before block application, 1st hour and 1st month after block. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores before blocks and one month after the blocks were evaluated.

Demographic characteristics of the patients were given in the Table 1. The mean pain score before blocks was 7,93 ± 1,18 and significantly decreased to 1,54 ± 1,10 after the blocks (Table 2). Mean WOMAC scores before blocks was 69,93 ± 15,02 which was decreased to 42,07 ±14,85 one month after the blocks. No muscle weakness, motor block or block-related complications were observed.

The anterior nerves of the knee (ANK) block provided sufficient analgesia in patients with chronic knee pain. The block possibly covers the nerves to vastus lateralis, vastus medalis, vastus intermediate and the anterior branch of the obturator nerve, and terminal branches of the superolateral and superomedial genicular nerves. The ANK block can be suitable for patients having knee pain at anterior region.

The retroclavicular approach to brachial plexus block (RAPTIR) has gained attention for potentially offering several advantages over traditional techniques. It offers potentially better needle view, reduced risk of vascular puncture and improved patient comfort. This case shows its advantage in a patient with complex anatomy, characterized by a deep deltopectoral groove and a prominent humerus, where the traditional infraclavicular approach is difficult. During this procedure, a linear ultrasound transducer is positioned vertically inferior to the clavicle, lateral to the midclavicular line. The needle is then inserted in a caudad direction, superior and posterior to the clavicle.

A 46-year-old man, ASA II, underwent right hand amputation under balanced general anesthesia following a crush injury. At the end of surgery, a brachial plexus block was performed via a retroclavicular approach with continuous catheter placement. Fifteen milliliters of 0.2% ropivacaine were administered. Postoperative analgesia included 10 mL of 0.2% ropivacaine every four hours via the catheter, with additional 5 mL boluses available as needed (1-hour lockout). Systemic analgesics included paracetamol 1 g every 8 hours, metamizole 1 g every 8 hours, and tramadol 100 mg as needed. Pain intensity was assessed using the numeric rating scale immediately after surgery and at 2, 6, 12, 24, 36, and 48 hours postoperatively.

The patient's pain intensity was effectively controlled. At each evaluation the patient reported pain scores of 3 or less. Tramadol administration was not required throughout post-operative period.

This demonstrates the potential benefits of the retroclavicular approach for brachial plexus block when dealing with Complex anatomy as seen in this case. Furthermore, the case highlights the apparent opioid-sparing effect of the brachial plexus block with ropivacaine. The patient achieved adequate pain control with minimal reliance on oral opioids.

Patients with myasthenia gravis (MG) are at risk of myasthenic crisis and respiratory depression peri-operatively, with pain-induced stress as a potential trigger. Due to their sensitivity to neuromuscular blockers and opioids, minimising opioid use while ensuring adequate pain control is crucial. Regional anaesthesia can help achieve this balance. Here, we report a patient with MG undergoing lumbar laminoplasty, where total intravenous anaesthesia (TIVA) was combined with a thoracolumbar interfascial plane block (TLIPB) as an adjunct analgesic, reducing opioid use and ensuring safe peri-operative management. Written consent was obtained from the patient. A 60-year-old man (167 cm, 66 kg) with well-controlled MG (pyridostigmine 60 mg/day) underwent lumbar laminoplasty. TIVA with TLIPB was planned. After induction with propofol TCI, rocuronium 50 mg, and remifentanil, a Train-of-Four (TOF) count of 0 was confirmed, and intubation was performed. TLIPB was performed bilaterally at L4 under ultrasound guidance with 40 ml of 0.25% levobupivacaine. Anaesthesia was maintained with propofol (2.6 μg/ml) and remifentanil (0.1–0.15 μg/kg/min). Rocuronium 10 mg was additionally given intra-operatively. Fentanyl 100 μg was used for analgesia. Post-operatively, neuromuscular blockade was reversed with sugammadex 200 mg, and extubation was performed after confirming TOF ≥90% and adequate spontaneous breathing. Operation time was 1 hour 14 minutes. Post-operative analgesia included IV-PCA fentanyl (250 μg/24 h) and acetaminophen, maintaining an NRS of 3. No respiratory problems or myasthenic crisis symptoms occurred. TLIPB blocks posterior spinal nerve branches, providing effective analgesia from the dorsal midline to the lateral thorax and is useful for spinal surgeries spreading one to two vertebrae. While pain management is crucial in MG, opioid use must be minimised due to respiratory risks. TLIPB alone was insufficient but reduced opioid requirements, contributing to multimodal analgesia and safer peri-operative management. TLIPB may be a valuable option for pain management in MG patients undergoing spinal surgery.

Managing severe acute pain in patients with pathological fractures secondary to bone metastases poses a significant clinical challenge, negatively impacting their quality of life and the administration of oncological treatments. Systemic analgesia is often insufficient in these cases. Our objective is to present a clinical case that illustrates the effectiveness of using a femoral perineural catheter for controlling severe acute pain.

A 76-year-old patient experienced a severely painful pathological right femur fracture with significant functional impairment, which subsequently led to the diagnosis of stage IV lung adenocarcinoma with bone metastases. Due to inadequate pain control with intravenous analgesia and opioids, the Acute Pain Unit (APU) enhanced the multimodal approach by inserting an ultrasound- and neurostimulation-guided femoral nerve catheter.

The implementation of the femoral perineural infusion demonstrated high efficacy in achieving analgesia, obviating the need for morphine rescue doses. This significantly enhanced the patient’s comfort and psychological well-being, while facilitating in-hospital mobilization and transfers for radiotherapy at the referral center. The catheter remained fully functional and effective for 12 days.

This case underscores the critical role of continuous regional anesthesia in the management of severe acute pain associated with pathological fractures and bone metastases. It highlights that the efficacy of this approach hinges on three key pillars: precise catheter placement technique, optimal drug selection and dosing, and meticulous monitoring. Multidisciplinary collaboration among the APU, traumatology, and oncology proved essential for the holistic management of this patient.

Current regional anesthesia techniques used to anesthetize the intercostobrachial nerve (ICBN) for upper arm surgery either lack reliability or have increased procedural risks. Safer and more reliable regional anesthetic techniques are required to block the ICBN effectively. Here, we introduce a novel “axillary serratus anterior plane (A-SAP) block” for anesthetizing the ICBN to allow reliable surgical anesthesia for upper arm arteriovenous fistula (UA-AVF) creation.

We present three cases in which the A-SAP block and supraclavicular brachial plexus block was utilized in UA-AVF creation surgeries. The A-SAP block was administered with the patients in the supine position, ipsilateral shoulder abducted 90°, and externally rotated. A linear 15–4-MHz ultrasound transducer was placed at the mid-clavicular line immediately caudal to the clavicle and the 2nd rib was identified. The probe was slid caudally to the 3rd rib, and then laterally towards the anterior axillary line, while keeping the 2nd intercostal space in view. The caudal end of the ultrasound probe was then rotated laterally, with the cranial end pivoting on the 2nd rib to obtain a transverse orientation. The pectoralis major, pectoralis minor, serratus anterior, intercostal muscles, 2nd and 3rd rib, pleura, and the axillary compartment could be seen in this view. The block needle was inserted medial to the ultrasound transducer and was directed laterally using an in-plane approach to reach the fascial plane between the pectoralis minor and serratus anterior muscles. The fascial plane was hydrodissected towards the axillary compartment, lifting it off the serratus anterior muscle, where the local anesthetic was then deposited.

In all three cases, none of the patients required local anesthetic supplementation intraoperatively.

In this case series, we introduced the A-SAP block as a reliable technique for anesthetizing the ICBN, providing effective surgical anesthesia for UA-AVF creation.

Effective postoperative pain management is critical for optimizing recovery following hip surgeries. This study evaluated the outcomes of incorporating a cluneal nerve block as an adjunct to standard sciatic, femoral, and lateral femoral cutaneous nerve blocks in patients undergoing hip surgeries.

A retrospective review was conducted on eight patients who underwent hip surgeries at a single institution. Demographic data, surgical details, anesthesia protocols, and postoperative outcomes were analyzed. Pain scores, opioid consumption, and adverse events were recorded.

The study included patients with a median age of 73 years (range: 34–90), 62.5% of whom were female. Procedures performed included partial hip replacement arthroplasty (PHRA) in 37.5% (3/8), closed reduction internal fixation (CRIF) with intramedullary (IM) or proximal femoral nail (PFN) in 37.5% (3/8), open reduction internal fixation (ORIF) or external fixator removal in 25% (2/8). Opioid consumption was minimal, with no patients requiring rescue analgesia. No complications or adverse events were reported.

The addition of a cluneal nerve block to standard nerve block protocols effectively reduced postoperative pain scores and opioid use without complications in patients undergoing hip surgeries. These findings support the potential utility of cluneal nerve blocks in enhancing multimodal analgesia for hip surgeries, warranting further investigation in larger, controlled trials.

Distal femur fractures represent approximately 4–6% of all femoral fractures, primarily affecting elderly due to osteoporosis and fall risk. Surgical fixation is the standard treatment but poses anesthetic challenges, especially in patients with multiple comorbidities. While spinal anesthesia is preferred, peripheral nerve blocks offer a viable alternative in high-risk patients, minimizing systemic complications and providing effective perioperative analgesia.

A 66-year-old female with medical history of coronary artery disease, hypertension, type 2 diabetes mellitus, chronic kidney disease, liver cirrhosis with portal hypertension, esophageal varices, chronic anemia, and a recent episode of hepatic encephalopathy presented with a right distal femur fracture. Her coagulation profile showed an INR of 1.4 and prolonged PT. Given the high anesthetic risk, the decision was made to perform the surgery under regional anesthesia alone. Anesthetic Technique: Sciatic nerve block (anterior approach) (15ml of 0.25% Levobupivacaine) Femoral nerve block (15ml 0.25% levobupivacaine) Lateral femoral cutaneous nerve block (4ml 0.125% Levobupivacaine) Obturator nerve block (anterior branch) (8ml of 0.25% Levobupivacaine) Procedural sedation included a single 20 mg dose of ketamine and propofol infusion at 153 mg/hr. Hemodynamic stability was maintained with phenylephrine infusion.

Patient was monitored in PACU and did not require SICU admission. Two units packed RBCs transfused due to postoperative anemia. She remained stable throughout and experienced no anesthesia-related complications. Patients with liver disease, coagulopathy, and recent encephalopathy are at increased risk with both general and neuraxial anesthesia. Peripheral nerve blocks, when used appropriately and with proper monitoring, offer a targeted and safe alternative. Regional anesthesia also reduces opioid requirements, facilitating recovery and minimizing respiratory and cognitive complications, especially in elderly.

Peripheral nerve blocks can serve as an effective sole anesthetic technique in high-risk geriatric patients undergoing lower limb orthopedic surgery. This approach should be considered in patients for whom general or spinal anesthesia poses significant risk.

Modern medicine has led to the development of more minimally invasive procedures, which require anesthetic techniques that parallel these surgical advancements. Studies have shown that peripheral nerve block is an essential component of multimodal analgesia that is well-tolerated and may provide superior analgesia compared to other modalities.

This case report details a 47-year-old female patient with no known comorbidities who complained of chronic low back pain associated with bilateral numbness in the gluteal area. The patient underwent endoscopic lumbar discectomy at L5-S1 level under a single-level left-sided ultrasound-guided erector spinae plane block (ESP) and right sided thoracolumbar interfascial plane (TLIP) block with Dexmedetomidine as IV infusion for moderate sedation. 0.5% Bupivacaine isobaric 20ml on each side per level was used respectively.

The perioperative course was unremarkable, with lower pain scores, minimized opioid use, and higher patient satisfaction. This case study highlights the potential of ESP block and TLIP block combined with sedation as an effective anesthetic technique in future minimally invasive spine surgeries.

As applied to this case, the safety and efficacy profile of the ESP and TLIP block supports its consideration as a feasible option in pain management. Further clinical studies may be essential in establishing evidence-based and standardized protocols for its use as perioperative analgesia in spine surgeries.

Background and Aims: Peripheral nerve blocks (PNBs) offer significant benefits for perioperative analgesia, yet their use may vary due to implicit bias, institutional norms, or logistical constraints. These disparities raise ethical concerns, particularly regarding patient autonomy, justice, and equitable access. This audit aims to evaluate patterns of PNB utilisation across patient demographics, examine consent practices, and assess ethical considerations in regional anaesthesia delivery.

Institutional ethics approval will be sought prior to data collection. A retrospective audit will be conducted at a tertiary teaching hospital, reviewing medical records from a 12–18-month period for adult patients undergoing limb surgeries amenable to PNBs. Data Collection: Quantitative Component; 1. Patient demographics (age, gender, language, ASA status) 2. Surgical details (elective/emergency, type of procedure) 3. PNB use (yes/no, type of block) 4. Consent documentation (written, verbal, risks/alternatives, clinician role) 5. Outcomes (pain scores, opioid use, complications) Qualitative Component: 1. Content analysis of anaesthesia records and consent forms 2. Thematic review of how information is recorded regarding decision-making, patient understanding, and block rationale Ethical Framework: Findings will be interpreted using the principles of biomedical ethics:  Justice: Assessing disparities in block access  Autonomy: Evaluating quality and timing of consent  Beneficence & Non-maleficence: Balancing effective pain relief with safety and informed choice

We anticipate identifying variations in PNB utilisation and consent quality linked to non-clinical factors such as age, gender, and urgency of surgery. Qualitative analysis of documentation is expected to reveal institutional patterns and areas for ethical improvement. These insights will support more ethically sound and equitable anaesthesia practices.

This audit will offer a comprehensive evaluation of how regional anaesthesia is delivered through both clinical and ethical lenses. Findings will inform improvements in patient communication, equity in access to PNBs, and standardisation of consent processes aligned with ESRA recommendations.

The lumbar plexus is an effective technique for pain management in total hip replacement surgery. Pericapsular nerve group block (PENG) has also shown its effectiveness. Currently, fast-track surgical programs require pain management strategies that preserve quadriceps strength, for physiotherapy or same-day discharge. No evidence was found comparing these two approaches regarding pain or muscular strength.

Approval from the ethics committee and informed consent was obtained. The patients scheduled for primary total hip arthroplasty under spinal anesthesia were randomized into two groups. Group A received 20 ml 0.25% of levobupivacaine for lumbar plexus block, and in post anesthesia care unit (PACU) 20 ml of saline for PENG block. Patients in Group B 20 ml of saline for the lumbar plexus, and in PACU 20 ml of levobupivacaine 0.25% for the PENG block. Pain was assessed using the visual analogue scale (VAS), opioid consumption was recorded, and quadriceps strength was evaluated with the Oxford scale at 2 hours and between 24 to 72 hours postoperatively

33 patients were enrolled, randomized 14 to group A and 19 to group B, no demographic differences registered. No significant differences were found in VAS pain scores during rest and movement or in opioid consumption. The motor quadriceps strength was significantly less just in the PACU evaluation for lumbar plexus block

Both blockades effectively control postoperative pain in total hip replacement surgery. The lumbar plexus block affects quadriceps motor function during the first hours. PENG block could be a more suitable strategy for fast-track surgeries

Peripheral nerve blocks (PNBs) are extensively used as an important modality of peri-operative analgesia for a wide range of orthopaedic procedures. These regional procedures have been shown to reduce post-operative opioid requirements and pain scores. This audit aimed to assess the utilisation of PNBs in all elective and emergency non-spinal orthopaedic procedures.

A retrospective audit was conducted on 260 orthopaedic procedures over a 3-month period between November 2024 and January 2025. Data was compiled from operation notes and anaesthesia records, including type of procedure, type of PNB performed and whether an analgesic or surgical block was performed. A short survey was circulated to consultant anaesthetists asking what they believed the main barriers to PNBs are in their practice.

PNBs were performed in 28.08% of procedures. 3.85% of procedures did not have sufficient documentation to determine whether a PNB was performed. The most common procedures for upper and lower limb respectively, were 38 radius cases and 55 ankle cases. 31.58% of radius procedures received a PNB, while 29.09% of ankle procedures received a PNB (please see graphs). The results of our survey of consultant anaesthetists are still being assessed.

Peripheral nerve block utilisation rates were varied. The above results show suboptimal implementation, especially given how multiple studies have shown the positives of PNBs, such as a reduction in post-operative analgesia consumption. We will also analyse the results of our consultant anaesthetist survey on the main barriers to performing regional anaesthesia in their everyday practice.

Detection of failed nerve blocks remains a big problem in our modern busy clinical practice. Methods currently used are subjective and not always precise. Thermographic method is a promising objective, quantitative tool for this task. Still, questions remain about it: How long to wait for confirmation of a successful nerve block? Does choice of different local anesthetics influence speed of onset for temperature changes? The aim of our research was to answer these questions.

A prospective, randomized research done in the Hospital Of Traumatology and Orthopedics in Riga, with 35 elective patients collected. All patients recieved N. ischiadicus block in suprapopliteal approach, using ultrasound and nerve stimulator. 3 different local anesthetics were used in equipotent doses, fixed concentrations- 20ml of 0.25% bupivacaine[N= 10], 20 ml of 1% Lidocaine[N=12], 20ml of 0.375% Ropivacaine[N=13]. Before and for 45 minutes after nerve block for every minute pictures of the blocked foot were taken. Pictures were analysed using HICKMICRO official software program, with statistics done by LU Statistics Laboratory.

Using Wilcoxon range tests, statistically significant temperature changes compared to before nerve block (p<0.05) can be seen after 10 minutes for Ropivacaine, 15 minutes for Bupivacaine and Lidocaine. Using linear regression models, we can see that the fastest increase in temperature can be seen in Ropivacaine group up to 25 minutes with slope coefficent of 0.315, followed by Lidocaine (0.246) and bupivacaine (0.234) with R squared test describing how well models predict changes above 0.96 in all of them.

While ropivacaine group did show substantially faster speed of onset till 25th minute, from clinical standpoint there is not significant difference between different local anesthetics when using thermography method. On average, at least 10 minutes must pass to determine success of a nerve block.

Postoperative pain management in spine surgery remains challenging, often relying heavily on opioids. This study evaluated the analgesic efficacy of bilateral ESPB in reducing opioid consumption and improving pain control during major spine surgeries. Primary outcomes included total opioid consumption and NOL values. Secondary outcomes were postoperative pain scores, adverse events, and length of hospital stay.

This prospective study included 30 patients undergoing lumbar discectomy, spinal fusion, or laminectomy. Bilateral ESPB was performed preoperatively under ultrasound guidance. Intraoperative nociception was continuously monitored using the Nociception Level (NOL) index, an objective measure derived from physiological signals including heart rate, skin conductance, and photoplethysmography. NOL values between 10-25 were considered normal, with values outside this range for >60 seconds indicating nociceptive stimulation. Analgesia was titrated to maintain NOL within the target range. Postoperative pain was assessed using the Numeric Rating Scale (NRS) or NVPS-R. Primary outcomes included total opioid consumption and NOL values. Secondary outcomes were postoperative pain scores, adverse events, and length of hospital stay.

ESPB demonstrated effective pain control across all surgery types. Spinal fusion surgeries showed a mean NOL (9.67), compared to laminectomy (10.48) and discectomy (6.70). Mean total intraoperative remifentanil doses were 243.64±129.4 mcg, 180.56±65.47 mcg, and 87.76±55.6 mcg for fusion, laminectomy, and discectomy, respectively. Postoperative morphine consumption averaged 5.43±3.15 mg. Pain scores in the post-anesthesia care unit using VAS decreased from 2.57 on arrival to 0.87 after two hours. Complications were minimal, with urinary retention being the most common (20%).

Bilateral ESPB, combined with NOL-guided analgesia, effectively reduced opioid consumption and improved pain control in major spine surgeries. This technique demonstrated a favorable safety profile and ease of application, making it a promising option for perioperative pain management in spine surgery. Further large-scale, randomized controlled trials are warranted to validate these findings.

Shoulder surgery is painful and regional anaesthesia forms a key part of recovery, however an insensate limb can lead to patient dissatisfaction. The COMBINATION shoulder block is a novel hybrid regional block designed to enhance patient nerve block tolerability after shoulder surgery. Combining a short-acting, low-volume interscalene block (ISB) with a long-acting anterior suprascapular nerve block (aSSNB) may enhance the patient block experience.

Following receipt of ethical approval, an online survey was created to assess the post-block experience among patients undergoing varied shoulder surgical procedures at a private and public hospital. The survey comprised of questions related to demographics, patient centred experiences, rebound pain and block satisfaction.

This block produces long-acting analgesia while preserving ipsilateral hand motor function. Most participants had preserved hand motor function (83/84, 98.8%), some patients were able to use mobile telephones in the post-anaesthesia care unit. Negative effects from this block were minimal, severe post-block pain incidence was low (5/84, 6.0%) as was bother cause by the nerve block (6/84, 7.1%). All patients were willing for repeat block for future surgery (84/84, 100%).

This novel technique enhanced patient nerve block tolerability by preserving hand motor function, had low severe post-block pain risk as well as high willingness for future repeat block.

Lower limb amputations in patients with peripheral arterial disease present significant anesthetic challenges due to advanced age and multiple comorbidities. When general and neuraxial anesthesia are contraindicated, carry high risk, or are technically unsuccessful, peripheral nerve blocks may offer a safe and effective alternative.

An 89-year-old male (ASA III) was admitted with right hallux ischemia and necrosis, signs of local infection, and concurrent pneumonia. His medical history included atrial fibrillation on anticoagulation, hypertension, and hypertensive cardiomyopathy. He was started on piperacillin–tazobactam and scheduled for an above-knee amputation. Given the pulmonary infection, general anesthesia was deemed high risk. Spinal anesthesia was attempted using 8 mg levobupivacaine and 2.5 mcg sufentanil. Due to challenging anatomy and technical difficulty, three experienced anesthesiologists performed multiple punctures. Although cerebrospinal fluid was obtained, no sensory block developed, and the surgery was postponed. Four days later, considering the procedure's semi-urgent nature and persistent pneumonia, surgery proceeded under regional anesthesia. Ultrasound-guided peripheral nerve blocks were performed with 0.5% ropivacaine, targeting the femoral, sciatic, obturator, and lateral femoral cutaneous nerves. Supplemental moderate sedation was also used.

The nerve blocks provided adequate anesthesia for the procedure, which was completed without complications. The patient had an uneventful postoperative recovery and was discharged on postoperative day four. This approach has been shown to provide effective anesthesia with minimal hemodynamic instability in high-risk patients.

This case illustrates the utility of ultrasound-guided peripheral nerve blocks as a safe and effective anesthetic strategy in high-risk elderly patients, especially when both general and neuraxial anesthesia are contraindicated, carry high risk, or fail.

Thoracic surgery, vital for treating a range of pulmonary and mediastinal conditions, is often accompanied by intense postoperative pain, presenting a significant challenge in patient care. One promising approach that has garnered attention for addressing post-thoracotomy pain is the erector spinae plane block (ESPB). The site of action is ventral and dorsal rami of thoracic spinal nerves extending from T3 to T10. Leveraging the anatomical accessibility and nerve-blocking properties of the erector spinae muscle group, ESB holds promise as an adjunct to traditional analgesic modalities

A total of 76 patients were included in the study. All captured data was recorded manually and then presented in the form of frequencies (percentages) in tabulated form in Microsoft Word Office 365. All calculations were done manually.

A total of 76 erector spinae plane block related catheters were inserted in thoracic surgery patients. Tuohy’s needle was used for ESPB. Mean needle depth was 5cm and mean catheter depth was 11cm. Different concentrations of local anesthetics were used (0.1%, 0.2% and 0.25%) at different infusion rates (10ml/hour up to 20ml/hour). No complication was encountered during our study period.

Erector Spinae Plane Block provides the best pain relief with minimum complication risks and maximum postoperative benefits, including its use in patients with coagulopathy and systemic infections. So, ESPB catheter-based analgesia with continuous infusion (0.15 or 0.2% bupivacaine at 15-20ml/hour) should be the preferred mode of postoperative analgesia after thoracic surgery and the catheter can be kept for a maximum of 6 days. Hence, a collaborative approach is required between the thoracic surgeon and the anesthetist.

We run a well-established upper limb plastic surgery list in a large district general hospital in the north of England. This service evaluation examines the efficiency of the list and patient satisfaction. The list is split between expedited trauma cases in the morning and elective patients in the afternoon. Blocks are primarily brachial plexus blocks along with selected forearm peripheral nerve blocks, depending on requirements for hand innervation. Motor sparing blocks also enable on table functional assessment if required. These are performed with lidocaine and adrenaline for a quick onset of action.

Data was collected for the duration of 2024. This included 50 patients in total, with 35 followed up to assess patient satisfaction and 15 lost to follow up. Data includes operation room timings, operation and block type, along with local anaesthetic used. Historic data was used to compare these variables for patients who had a GA for similar procedures as a reference. Telephone follow up (35/50) allowed retrospective data collection on variables including pain during procedure and patient satisfaction.

Patients who received regional anaesthesia had a short length of stay, time in theatre before operating began and time between end of operation and discharge to the ward. The patients reported no nausea and vomiting, and had good overall experience scores, with 91% rating their experience 5/5, and 94% saying they would recommend the experience. Patients felt well informed (100% rated information given 5/5), and 97% had 5/5 confidence in the anaesthetist. The service was efficient - the interval between patient arrival to surgery start was on average 15minutes.

Within an established awake regional anaesthesia list, we can streamline patient experience utilising the multidisciplinary team including specialist nurses, surgeons, anaesthetic team and theatre staff, facilitating shorter length of stay with high patient satisfaction.

Bioimpedance refers to the resistance of biological tissues to electrical current. It has the potential to enhance the accuracy of peripheral nerve blocks by providing real-time feedback during regional anesthesia, complementing ultrasound and nerve stimulation techniques. This study assesses impedance variations during axillary peripheral nerve block. Understanding how impedance varies across different tissue types can help guide precise needle placement for block success, reducing complications such as intraneural or intravascular injections.

This prospective exploratory observational study included patients undergoing axillary nerve block for upper limb surgical procedures. Before the procedure, patients received 50µg of fentanyl and 1mg of midazolam, with continuous standard monitoring. An anesthesiologist performed nerve block under ultrasound guidance using nerve stimulation in sentinel mode (0.1ms, 0.5mA, 2Hz) with nerve stimulator device which continuously displayed electrical impedance. An assistant administered the local anesthetic, while another, blinded to the procedure, recorded impedance values across subcutaneous tissue, muscle, fascia, and nerves. A linear mixed model was performed to assess impedance across tissue types, using tissue type as a fixed effect and subject-level random effects to account for variability, with random slopes that captured within-subject variation. Statistical analysis was conducted using STATA-18.

Among 74 participants (mean age: 54), impedance (kΩ) was recorded across tissue types: subcutaneous (5.2–18.7), muscle (5.3–17.7), fascia (4.7–17.7), radial nerve (4.2–11.8), and median nerve (3.7–11.5). A clear decrease in impedance was observed from subcutaneous tissue to median nerve. Bonferroni-corrected pairwise comparisons showed significant differences (p<0.05) between various tissue types and nerves. A borderline difference appeared between fascia and the median nerve. No complications (intraneural/intravascular injections) were detected.

The observed trend demonstrates a consistent reduction in impedance values as the needle advances toward the target nerves. Incorporating impedance monitoring may improve nerve block accuracy by serving as an additional parameter for guiding needle placement through different tissue layers.

Electrical storm (ES) is a life-threatening condition defined as three or more episodes of ventricular arrhythmia (VA) within 24 hours. It poses a significant clinical challenge, especially when standard anti-arrhythmic therapies fail. In refractory cases, stellate ganglion block (SGB) has emerged as a promising therapeutic option.

A 55-year-old man with hypertension and extensive coronary artery disease, who had previously experienced two episodes of ES and received an implantable cardioverter-defibrillator (ICD), was admitted with drug-refractory ES. ICD recorded more than 20 shocks before admission. In the intensive care unit, the patient continued to present with recurrent VA with hemodynamic instability, requiring repeated cardioversion. An ultrasound-guided continuous left SGB was performed. A bolus of 8 mL of 0.2% ropivacaine was administered, followed by a continuous infusion at 3 mL/h via an elastomeric pump.

Within 10 minutes, the patient developed sinus bradycardia and achieved hemodynamic stabilization. Continuous SGB was maintained until catheter ablation was accomplished.

Even after reversible causes have been addressed and anti-arrhythmic therapy initiated, catheter ablation is still often required to achieve long-term control of ES, though it may not be immediately available. Both thoracic epidural anesthesia (TEA) and continuous SGB have proven efficacy in managing refractory cases. Compared to TEA, SGB is easier to perform, less invasive and associated with fewer complications. The continuous approach, in particular, offers extended sympathetic blockade with sustained arrhythmia suppression, standing as a valuable bridging strategy until definitive treatment can be completed.

A 98-year-old, 55-kilogram female with a history of hypertension, hypothyroidism and previous segmental mastectomy for HER2+ invasive ductal carcinoma of the right breast presented with recurrent breast cancer, scheduled for total mastectomy with axillary lymphadenectomy. She strongly expressed the decision to not undergo general anesthesia with tracheal intubation for surgery due to several reasons: 1) an active out of operating room ‘do not resuscitate’ and ‘do not intubate’ status (DNR/DNI), 2) concern for prolonged postoperative recovery and delirium, 3) cardiac risks with general anesthesia given her advanced age.

To comply with patient preference and avoid the risks of general anesthesia, regional anesthesia was primarily utilized. Given her "oldest-old" age and low weight, the intended local anesthetic volume had to be divided efficiently to cover the targeted lesions for surgery. (Figure 1) Ultrasound-guided paravertebral blocks were performed at the right T3 and T5 levels to provide T2-T6 dermatomal coverage.1 A pectoserratus block was added to anesthetize the deep axillary structures.2,3 (Figure 1)

Following the regional anesthetic interventions, intraoperative sedation for patient comfort included low-dose remimazolam, fentanyl, and a propofol infusion (Figure 2). Throughout the 2.5 hour surgery, she maintained spontaneous ventilation with a simple facemask, reported no discomfort, and remained hemodynamically stable. Postoperatively, the sedatives offset quickly and she denied any nausea or pain related symptoms. On postoperative day (POD) 1, the patient continued to recover with no pain, cognition at baseline, and no perioperative complications. She was discharged on POD3.

Combined paravertebral and pectoserratus plane blocks can be an effective primary anesthetic and postoperative analgesic for a high-risk, geriatric patient undergoing breast cancer resection. Sedation can accompany the nerve blocks to reduce anxiety and help the patient lay still for optimal operating conditions; choosing short acting options can reduce the chances of postoperative delirium in this high-risk patient population.4,5

Peripheral nerve blocks (PNBs) offer significant benefits in surgical anaesthesia and postoperative pain control. However, informed consent for regional anaesthesia is often variable in quality and timing, particularly in emergency settings or when time is limited.This retrospective audit aims to evaluate the quality and completeness of consent documentation for PNBs, and to identify ethical concerns related to patient autonomy, communication, and decision-making practices.

We will conduct a retrospective audit of adult patients who received peripheral nerve blocks over a 12-month period at a tertiary care teaching hospital. The review will include anaesthesia records, consent forms, and perioperative documentation. Key variables will include: 1. Presence and type of documented consent (written, verbal, none) 2. Timing of consent (preoperative clinic, day of surgery, intraoperative) 3. Documentation of key elements: risks, benefits, and alternatives 4. Clinician obtaining consent (consultant, trainee) 5. Patient characteristics (age, gender, ASA status, language barriers, urgency of surgery) Data will be analysed descriptively, with subgroup comparisons to explore potential disparities.

We anticipate identifying frequent omissions in consent documentation, especially among high-risk or emergency cases. Gaps in communication or delegation of consent-taking to junior staff may raise ethical concerns about voluntariness and shared decision-making. These findings are expected to inform improvements in institutional consent practices and training.

This audit will highlight documentation and ethical gaps in informed consent for regional anaesthesia. Addressing these issues is essential to uphold patient autonomy, improve communication, and align practices with ESRA-recommended standards. The study aims to support the development of structured consent protocols for PNBs within anaesthesia departments.

Adults with congenital heart disease (ACHD) undergoing cardiac surgery are increasingly common and present unique anesthetic challenges due to complex cardiac physiology and high perioperative risk. While regional anesthesia reduces time to extubation and hospital length of stay (LOS) in pediatric congenital heart surgery (1), similar literature in ACHD is limited. This case series details individualized regional anesthesia as part of multimodal analgesia to optimize outcomes in this unique population.

Three ACHD underwent subrectus epicardial pacemaker insertion or generator exchange. Patient 1 underwent generator exchange with extension of midline sternotomy from midsternum to subxiphoid. They received left T5-9 intercostal nerve blocks and right parasternal intercostal fascial block (PIFB). Patient 2 underwent epicardial pacemaker insertion, attempted via subxiphoid sternotomy then converted to full sternotomy. They received bilateral T6-7 and left T8-9 paravertebral blocks (PVB) and additional bilateral PIFB after incision extension. Patient 3 had a staged procedure: firstly, a redo sternotomy with temporary epicardial pacemaker pacing leads and received bilateral multi-orifice PIFB catheters. Subsequently, Patient 3 had a left thoracotomy for pacemaker insertion and sternotomy VAC dressing closure and received left T3-7 intercostal nerve cryoneurolysis.

All patients were extubated by 0-4 hours post-op and reported almost no surgical incisional pain in the first day. Analgesia was superior to previous surgeries with similar incisions, and opioid consumption in the first 24 hours was minimal. LOS varied from 2 to 20 days for reasons outside of pain management. In all cases, pain was more prominent at the chest tube insertion site than the surgical incision.

Regional anesthesia was effective in managing postoperative pain in ACHD undergoing epicardial pacemaker procedures. Despite major surgical incisions, patients were extubated quickly and required minimal opioids in the first 24 hours. Further research is needed to assess the broader benefits of these techniques in the growing ACHD population.

Total knee arthroplasty (TKA) causes significant postoperative pain that may delay recovery. This article compares two nerve block combinations: Femoral Nerve Block (FNB) with Lateral Femoral Cutaneous Nerve Block (LFCNB), and Sciatic Nerve Block (SNB) with Saphenous Nerve Block via the Adductor Canal Block (ACB), evaluating anatomical targets, analgesic coverage and motor effects. №1 – FNB + LFCNB Good for anterior and lateral pain Doesn`t address posterior pain High fall risk due to quadriceps weakness №2 – SNB + ACB Comprehensive analgesia (anterior + posterior) Preserves quadriceps function Possible foot motor weakness if SNB too distal Evidence-Based Comparison SNB + ACB: Better early mobility, lower fall risk, more complete analgesia FNB + LFCNB: Higher motor impairment, limited coverage Overview of Each Nerve Block FNB: Anterior coverage LFCNB: Cutaneous only ACB: Medial/anterior knee SNB: Posterior knee coverage

In a retrospective study (May 1–June 1) 20 TKA patients were evaluated: 10 received FNB + LFCNB and 10 received SNB + ACB. Nineteen had spinal anesthesia; one had general. All blocks were given postoperatively. Patients receiving SNB + ACB experienced more comprehensive analgesia and better motor preservation, supporting its use in ERAS protocols.

Use SNB + ACB for most modern TKA protocols Reserve FNB for specific cases where motor block is acceptable Tailor based on patient risk, surgical technique and institutional ERAS

Optimal nerve block choice boosts TKA recovery. The SNB + ACB combination offers effective, motorsparing analgesia, reduces fall risk and supports early rehabilitation, making it well-suited for modern ERAS protocols.

Proper documentation is an integral part of healthcare service delivery. It facilitates continuity of care and has a medicolegal aspect. In our previous audit, we reviewed 100 medical records to check effective documentation of Stop Before You Block (SBYB). There was no documentation of SBYB in 41% of the reviewed charts. Ahmed and colleagues have recently published recommendation for effective documentation in regional anaesthesia. The aim of this project is to design, implement and assess compliance of a single paper chart for documentation in regional anaesthesia according to the latest expert recommendations.

Leeds Teaching Hospitals is one of the biggest NHS trusts across UK. Estimated annual block procedures in LTHT is around 9000. We aimed to create a single chart following the latest expert recommendations. 6 months later, we have audited the compliance to the newly designed chart.

After serial design changes, to make it concise, inclusive and easy to use. We have finalised a single chart for documentation in regional anaesthesia (figure 1) which has been approved by our local quality committee. It is now the sole anaesthetic record employed in the Trust and in our hand surgery unit where regional anaesthesia is the main mode of anaesthesia. We have reviewed 50 anaesthetic charts and assessed the compliance to fulfill the chart. We achieved a good compliance in the reviewed charts (figures 2,3)

We have designed, implemented and assessed compliance of a regional anaesthesia documentation chart following experts’ recommendations. This has achieved standardisation of documentation in our Trust.

Despite proven efficacy in knee arthroplasty, the role of adductor canal block (ACB) and the infiltration between the popliteal artery and posterior capsule of the knee (iPACK) block in managing pain and improving function after anterior cruciate ligament (ACL) reconstruction is not yet well defined. This randomized controlled trial aimed to determine whether ACB combined with iPACK block offers superior postoperative analgesia compared to ACB alone.

After ethical approval 54 consenting patients undergoing ACL reconstruction under spinal anesthesia were randomly received either ACB with iPACK block (Group-I) or ACB alone (Group-C). The primary outcome was pain intensity at rest at six hour postoperatively, measured using a numerical rating scale (NRS,0-10). Pain at 12, 18, and 24 hours postoperatively, total morphine consumption in the first 24 hours after surgery, patient satisfaction and postoperative functional outcomes including Lysholm score and International Knee Documentation Committee (IKDC) score up to 1 year later were secondary outcomes.

Baseline characteristics were similar between groups (Table 1). At 6 hours, pain scores at rest were not significantly different (median NRS: Group-I, 0 [0–1] vs. Group-C, 2 [0–3]; p = 0.053). However, Group-I demonstrated significantly lower pain scores at rest and with movement at subsequent time points (Table 2). No significant differences were observed in morphine use, satisfaction, or functional outcome scores (Table 3).

While combining ACB with iPACK block improved analgesia at later stages following ACL reconstruction, overall pain levels were mild in both groups, and differences may have limited clinical significance.

Effective documentation is an integral part of healthcare service delivery. It facilitates continuity of care and has a medicolegal aspect. In our previous audit, we reviewed 100 medical records to assess documentation of Preparation Stop Block (PSB). There was no documentation of PSB in 41% of these records. A group of experts have recently published recommendations for effective documentation in regional anaesthesia. The aim of this project was to design, implement and assess compliance of a single paper chart for documentation in regional anaesthesia in accordance with the latest expert recommendations.

Leeds Teaching Hospitals Trust (LTHT) is one of the largest NHS hospitals in the UK with around 9000 regional nerve blocks being performed annually. After reviewing latest recommendations and collating departmental feedback, we developed a dedicated regional anaesthetic chart which was introduced to LTHT and subsequently reviewed to assess compliance.

Following serial design changes, we have finalised a single chart for documentation in regional anaesthesia (figure 1) which has been approved by our local quality committee and employed as part of LTHT documentation. This chart is now the sole anaesthetic record utilised on the hand surgery unit at LTHT where regional anaesthesia is the main mode of anaesthesia. We have since reviewed 50 of these anaesthetic charts to assessed compliance. PSB was documented in 90% of records with good compliance in other domains (figure 2,3)

We have designed, implemented and assessed compliance of a dedicated regional anaesthetic chart following expert recommendations. This has achieved standardisation of documentation at LTHT.

73-year-old female patient underwent total knee arthroplasty under regional anesthesia. A combination of peripheral nerve blocks was performed using ultrasound guidance and nerve stimulator to ensure accurate localization. The femoral, sciatic, lateral femoral cutaneous (LFCN) and obturator nerves were selectively blocked providing effective intraoperative anesthesia and postoperative analgesia.

Preoperatively femoral and sciatic nerves were each injected with 12mL of 0,5% levobupivacaine combined with 4mg of dexamethasone, respectively. Additional blocks of LFCN using 4mL of 0,25% levobupivacaine and obturator nerve using 8mL of 0,25% levobupivacaine were performed. The patient was sedated with 25mg ketamine, 5mcg sufentanyl, 2mg midazolam, and TCI of propofol at an effective plasma concentration of 0,6mcg/mL. Supplemental oxygen was delivered via face mask at 6 L/min. The patient was hemodynamically and respiratory stable throughout the procedure.

Following surgery the patient was transmitted to the ward. No additional analgesia was required in the first 24 hours postoperatively. The effect of the peripheral nerve block lasted approximately 25 hours. At 25 hours postoperatively, the patient complained of pain score of 2-3 out of 10 and received 100 mg ketoprofen. The operated leg was placed in a continuous passive motion device (Kinetec). Upon later mobilization she reported pain 2 out of 10, while at rest she reported no pain.

This case demonstrates that multimodal peripheral nerve blocks combined with light sedation can provide effective anesthesia and prolonged postoperative analgesia in total knee arthroplasty. This approach minimizes opioid requirements, supports early mobilization and enhances patient comfort and recovery.

Unplanned conversion from laparoscopic to open liver surgery presents significant challenges in postoperative pain management. The external oblique intercostal (EIO) plane block has emerged as a promising technique for upper abdominal wall analgesia. We present a case of successful pain management using continuous EOI plane block following unplanned conversion to open liver resection.

A 69-year-old ASA III male with metastatic colorectal cancer required conversion to open subcostal liver resection after intraoperative bleeding compromised the laparoscopic approach. Intraoperative analgesia included paracetamol, tramadol, parecoxib and morphine (total of 3mg). Postoperatively, we performed an ultrasound-guided EOI plane block at the right sixth rib (transverse orientation, linear probe) using 20 mL of 0.2% ropivacaine. A catheter was placed for administration of 0.1% ropivacaine via programmed intermittent bolus (10 mL/hour) with patient-controlled boluses (10 mL, 30-minute lockout). Intravenous adjuncts included paracetamol (1 g 6/6h), parecoxib (40 mg 12/12h), and rescue morphine.

The patient was extubated uneventfully and transferred to the ICU. He maintained optimal pain control throughout recovery, reporting only mild incisional pain at maximum intensity while requiring no supplemental opioids after the first 24 hours. The perineural catheter was removed on postoperative day 2. The patient achieved progressive recovery of autonomy and was discharged on day 4.

The continuous EIO plane block provided effective analgesia, avoiding the need for neuraxial approaches in the postoperative period or prolonged opioid use. This technique may be a viable alternative for unplanned open liver surgery, but more evidence is needed to validate its efficacy in complex abdominal procedures.

Awake upper limb surgery is a technique that offers numerous benefits over general anaesthesia methods. Patients benefit from a faster recovery time, experience less postoperative pain and fewer side effects such as post operative nausea and vomiting. Awake surgery facilitates early mobilisation, which can significantly improve the functional recovery of the upper limb. We wanted to assess the patient experience of awake upper limb surgery.

Between May 2024 and January 2025, data were collected from 50 patients undergoing awake upper limb surgery. The study aimed to evaluate various aspects of the procedure, including the patient experience, the need for supplemental nerve blocks, the necessity for sedation, and instances requiring conversion to general anaesthesia. A postoperative phone interview was conducted with each patient to complete a questionnaire that evaluated the adequacy of preoperative information regarding procedural expectations and overall satisfaction.

94% of patients report being satisfied with their anaesthetic, with 90% indicating they would recommend the procedure to friends. 18% required sedation. Supplementary local anaesthetic top-ups were necessary in 11% of cases, while only 3% of patients required conversion to general anaesthesia. 89% of cases were completed as day cases, with the mean duration of stay in recovery being 94 minutes.

The results suggest that patients have an overall positive experience with awake upper limb surgery. This approach is expected to continue expanding within the field of anaesthesia. It offers significant advantages in terms of patient care, including reduced length of stay and fewer complications.

Over 3000 cataract surgeries are performed each year in our hospital. We noticed that many anaesthetic trainees in our department were uncomfortable performing ophthalmic blocks. Our aim was to evaluate current practices, comfort level and challenges related to regional anaesthesia for ophthalmic surgery in our department.

We developed an anonymous online survey consisting of 15 questions to assess individual practice, comfort levels and perceived barriers to performing ophthalmic blocks. The survey was distributed to 93 members of the Department of Anaesthesia, with a response rate of 39 (41%). The respondents included 16 consultants and 23 non consultant hospital doctors (NCHDs). Trainees were categorised by call tier, with those on 3rd on-call tier (senior tier) designated as ”senior registrar.”

We found that most trainees regularly covering ophthalmology lists had not performed any blocks in the past 2 years. Only 20% of senior registrars felt they had received enough exposure to ophthalmology blocks during their training. Of the entire group surveyed, only 33% felt comfortable performing sub-tenon blocks. We also asked respondents to identify specific barriers to performing more ophthalmic blocks. Half reported that a key obstacle was the preferential allocation of learning opportunities to ophthalmology trainees. Other barriers included inexperience, fear of chemosis and fear of causing complication.

The findings highlight a significant gap in training among anaesthetic trainees. Targeted educational initiatives, including structured teaching and closer collaboration with ophthalmology, could help overcome key barriers and enhance both confidence and clinical practice in this area.

The free fibula flap is a versatile option for reconstructing bone defects. Its success depends on meticulous perioperative planning due to microvascular complexity and dual surgical fields. This case highlights perioperative strategies supported by current evidence.

A 36-year-old male with diaphyseal humeral pseudoarthrosis after multiple surgeries for a blast-related fracture underwent a 7cm free fibula flap transfer from the right leg. Simultaneous donor and recipient site surgeries were performed under general anesthesia and dual ultrasound-guided blocks: a popliteal-sciatic block (20mL levobupivacaine 0.25%) in supine position for the donor site, and a supraclavicular continuous block (20mL levobupivacaine 0.25% plus lidocaine 1% reinforcement boluses) for the recipient site. The 10-hour procedure involved 1L blood loss, managed with tranexamic acid, fibrinogen, and transfusion. Hemodynamic and gasometric monitoring ensured stability without vasopressors. A Doppler probe was used for flap monitoring. Postoperative continuous analgesia via catheter and PCA was effective, avoiding opioid rescue. Doppler signals remained stable, and the patient was discharged without complications.

Free flap failure ranges from 1–5%, especially in trauma and early postoperative periods. Preoperative optimization of hemoglobin, glucose, and nutrition, and maintaining perfusion and oxygenation delivery intra- and postoperatively, are essential. General anesthesia is preferred for complex surgeries, while regional blocks may enhance perfusion via sympathetic blockade, though evidence is limited. Hemodynamic control, cautious use of vasopressors and tranexamic acid, goal-directed fluid therapy, early thromboprophylaxis, and monitoring are crucial.

Free flap reconstruction requires multidisciplinary planning and precise perioperative care. Further evidence is needed regarding regional anesthesia and transfusion strategies in microsurgery.

The free fibula flap is a versatile option for reconstructing bone defects. These are long surgeries with microvascular approaches. Anesthesia management is important for hemodynamic maintenance of the graft and pain control. This case highlights perioperative strategies supported by current evidence.

A 36-year-old male with humeral pseudoarthrosis after multiple surgeries for a blast-related fracture underwent a 7cm free fibula flap transfer from the right leg. Simultaneous donor and recipient site surgeries were performed under general anesthesia and dual ultrasound-guided blocks: a popliteal-sciatic block (20mL levobupivacaine 0.25%) for the donor site, and a supraclavicular continuous block, posterolateral approach in plane, between the upper and middle trunk (20mL levobupivacaine 0.25% + lidocaine 1% reinforcements) for the recipient site. The 10-hour procedure involved 1L blood loss, managed with tranexamic acid, fibrinogen, and transfusion. Hemodynamic and gasometric monitoring ensured stability without vasopressors. A Doppler probe was used for flap monitoring. Postoperative analgesia consisted of continuous infusion of 0.125% levobupivacaine at 4 mL/h via supraclavicular catheter and Patient Controlled Analgesia, achieving NRS < 3 and avoiding opioid rescue. Doppler signals remained stable, and the patient was discharged without complications.

Free flap failure ranges from 1–5%, especially in trauma and early postoperative periods. General anesthesia is preferred for complex surgeries, and regional blocks improve perfusion via sympathetic blockade, minimizing thrombosis risk. Perioperative pain management with continuous blocks reduces stress and vasospasms, protecting the flap.

Free flap reconstruction demands multidisciplinary planning. Regional anesthesia protects the flap and reduces opioid consumption, though further evidence is needed in microsurgery.

Post-dural puncture headache (PDPH) is a significant complication after neuraxial anesthesia. The current gold standard treatment for PDPH is the epidural blood patch (EBP), which is highly effective but invasive and carries procedural risks. Therefore, less invasive regional techniques such as occipital nerve blocks (ONBs) and sphenopalatine ganglion blocks (SPGBs) have gained attention. This case series aims to compare the short-term effectiveness of ONBs and SPGBs in PDPH management.

Seven female patients aged 27–41 developed PDPH following spinal anesthesia. All patients underwent neurological examination and received conservative treatments including hydration, caffeine, NSAIDs, and bed rest. Four patients received bilateral ONBs (greater and lesser occipital nerves together) and three patients received bilateral transnasal SPGBs. All procedures utilized a combination of 15 mg bupivacaine %0,5 and 20 mg methylprednisolone. Pain intensity was assessed using a visual analog scale (VAS) in both supine and upright positions at 0, 5th minute, 20th minute, 6th hour, 24th hour and 5th day. Patients were followed regarding recurrence and adverse effects.

All patients experienced rapid VAS reduction post-procedure. ONBs provided sustained pain relief with no recurrence in all four cases. SPGBs also resulted in prompt pain relief, but one patient reported recurrence of neck pain and was lost to follow-up. The median initial VAS was 9/10, which dropped to ≤2/10. No adverse events were reported.

Both ONBs and SPGBs appear to be effective interventions for PDPH when conservative treatments fail. Our results support the need for larger comparative studies to determine long-term efficacy and optimal patient selection.

Oncologic surgery of the musculoskeletal system is frequently aggressive and associated with significant postoperative pain. These procedures often involve atypical tumor locations, which may necessitate unusual surgical approaches. As a result, the placement of peripheral nerve catheters can be limited, particularly when the standard insertion site lies within the surgical field. Alternative strategies must be considered to ensure adequate analgesia in the postoperative period.

We present the case of an 18-year-old male who underwent an en bloc resection of a peroneal Ewing’s sarcoma involving both bone and adjacent soft tissues. The surgical incision extended across the lower third of the lateral compartment of the leg, precluding the standard placement of a popliteal nerve catheter. Additionally, the patient’s anatomy presented challenges to more proximal catheter placement using conventional ultrasound-guided techniques. To overcome these limitations, the surgical team opted for intraoperative placement of a peripheral nerve catheter under direct vision prior to wound closure. This approach ensured accurate positioning while avoiding contamination of the surgical field.

The patient retained the catheter for seven days postoperatively, during which he experienced excellent pain control (Visual Analog Scale <3), with only one transient episode of higher pain (VAS 6) that responded to a morphine bolus. No complications related to the catheter were observed. The patient was discharged on postoperative day 10 without incident.

In conclusion, we suggest that intraoperative placement of peripheral nerve catheters by the surgical team may be a safe and effective alternative when standard approaches are contraindicated or technically challenging.

Severe aortic stenosis presents major anesthetic challenges during urgent non-cardiac surgery due to the high risk of hemodynamic instability and perioperative cardiac complications. The primary anesthetic concern is to maintain hemodynamic stability by avoiding hypotension, tachycardia, and abrupt changes in preload and afterload. Without prior cardiac intervention, choosing an anaesthetic technique with minimal cardiovascular risk is crucial. Peripheral nerve blocks may offer a safer alternative in this high-risk population.

We report the case of a 69-year-old female (ASA-PS IV) with symptomatic severe aortic stenosis (mean pressure gradient of 44mmHg), awaiting surgical aortic valve replacement, who sustained a distal radius fracture requiring urgent surgical fixation. Standard ASA monitoring was applied, along with invasive blood pressure monitoring via a radial arterial catheter. To minimize cardiovascular instability and mitigate the risks associated with general anesthesia, a regional anesthetic technique was selected. An ultrasound-guided axillary brachial plexus block was performed using 25 mL of 0.5% ropivacaine.

The peripheral nerve block provided effective surgical anesthesia, and the patient remained hemodynamically stable throughout the procedure, not requiring any hemodynamic support. The patient was admitted to an intermediate care unit for postoperative surveillance. Postoperative recovery was uneventful, with adequate analgesia and no cardiovascular complications were recorded.

Peripheral nerve blocks represent a valuable anaesthetic approach for orthopaedic surgery in patients with severe aortic stenosis. This case reinforces the role of regional anaesthesia as a safe and effective strategy in high-risk cardiac patients undergoing urgent non-cardiac surgery.

The combined use of brachial plexus block has been demonstrated to decrease the need for general anesthetics, reduce associated side effects, and enhance early postoperative analgesia. Nonetheless, once the nerve block effect subsides, patients occasionally report experiencing severe pain, a phenomenon identified as rebound pain. The factors contributing to rebound pain are not yet fully understood. This study investigates the incidence and factors associated with rebound pain in patients undergoing brachial plexus block for shoulder arthroscopic surgery.

This study included patients who underwent arthroscopic rotator cuff tear repair between January 2020 and March 2025. All patients received a combination of brachial plexus block and general anesthesia. Rebound pain was defined as an increase from a Numerical Rating Scale (NRS) score of ≤3, indicating an effective block, to an NRS score of >7 within 24 hours post-surgery when the block effect had dissipated. Patient characteristics, surgical factors, and anesthetic factors were analyzed for their association with the incidence of rebound pain. Statistically significant indicators were identified, and a multivariate logistic regression analysis was performed to determine the risk factors associated with rebound pain.

Of 336 patients, 148 (44.1%) experienced rebound pain. Multivariate logistic regression identified dexamethasone use (OR 0.43, 95% CI 0.207-0.893, p=0.0237) and levobupivacaine choice (OR 0.260, 95% CI 0.107-0.633, p=0.0030) as independent factors associated with rebound pain.

Consistent with previous studies, rebound pain was observed in nearly half of the patients. Our study demonstrated that intravenous dexamethasone and levobupivacaine use effectively reduce the incidence of rebound pain.

The erector spinae plane block (ESPB) has emerged as a promising regional anesthesia technique in pediatric surgery, yet its effectiveness in pediatric renal procedures remains underexplored. This systematic review and meta-analysis aims to evaluate the efficacy and safety of ESPB compared to standard analgesic approaches and other regional block techniques in children undergoing kidney surgeries.

Following PRISMA guidelines, a comprehensive search of MEDLINE, Cochrane Library, and Scopus was conducted up to April 2025. Randomized controlled trials assessing ESPB for postoperative pain management in pediatric renal surgeries were included. Outcomes analyzed include post operative pain scores, opioid consumption, time to first rescue analgesia, postoperative nausea and vomiting (PONV), and complications.

Five randomized controlled trials encompassing 326 patients were included. Compared with control, erector spinae plane block (ESPB) did not significantly reduce the need for rescue analgesia or prolong the time to first rescue analgesia . Postoperative pain scores tended to be lower in the ESPB group during the first 24 hours, particularly in one trial showing a consistent analgesic advantage. Incidence of postoperative nausea and vomiting and complications were not significantly different between groups. Overall, ESPB demonstrated a favorable safety profile with variable analgesic benefit across studies.

Erector spinae plane block is a safe technique that may help reduce early postoperative pain in children undergoing renal surgery. However, it failed to show superiority in reducing rescue analgesia requirement or minimizing complications. More high-quality studies are needed to confirm its effectiveness and guide its routine use in pediatric renal surgeries.

We have previously demonstrated that an extrafascial injection of 20 ml of local anaesthetic for interscalene brachial plexus block (ISB) 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 vs a volume of 20 ml, while providing similar analgesia.

Sixty ASA physical status 1-3 patients scheduled for elective shoulder surgery under general anaesthesia were randomised to receive ultrasound-guided extrafascial ISB using ropivacaine 0.75% 20 ml (control group) or 10 ml (low volume group) injected laterally 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 min after the procedure. Secondary outcomes included duration of analgesia and i.v. morphine consumption at 24 h after surgery.

The 30-min 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). Participants in the low-volume vs control group had a shorter duration of analgesia (550 vs 873 min; P<0.01) and higher i.v. 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.

Intravenous dexamethasone and dexmedetomidine are two adjuncts to local anaesthetics used independently to prolong analgesia after peripheral nerve block. This randomised, controlled, triple-blinded trial tested the hypothesis that the intravenous combination of dexamethasone and dexmedetomidine would provide superior analgesia than intravenous dexamethasone alone in patients undergoing upper limb surgery with a supraclavicular brachial plexus block.

A hundred patients were randomised to receive intravenously either dexamethasone 0.15mg.kg-1 (Dexagroup) or a combination of dexamethasone 0.15mg.kg-1 and dexmedetomidine 1μg.kg-1 (Dexa-Dexme group). The primary outcome was the duration of analgesia measured from the time of block procedure to first oral opioid intake. Secondary outcomes included duration of sensory and motor blocks, pains scores at rest and on movement, cumulative oral morphine consumption at 48h and incidence of hypotension episodes and bradycardia.

The mean (standard deviation) duration of analgesia was 690 min (544 min) in the Dexa group and 621 min (334 min) in the Dexa-Dexme group (p=0.47). Similarly, there were no significant differences in all the secondary outcomes.

The intravenous combination of dexamethasone and dexmedetomidine does not provide superior analgesia than intravenous dexamethasone after a supraclavicular brachial plexus block.

Endobronchial ultrasound and diagnostic bronchoscopy are essential tools in pulmonary medicine, but are often associated with significant patient discomfort when performed under moderate sedation. This case study highlights the effectiveness of targeted airway nerve blocks in optimizing patient tolerance and procedural conditions during the such procedures.

A 31-year-old female underwent outpatient endobronchial ultrasound and bronchoscopy for evaluation of mediastinal lymphadenopathy. Anesthesia was achieved with bilateral glossopharyngeal, bilateral superior laryngeal, and translaryngeal nerve blocks. These blocks suppress the cough and gag reflexes, improving patient comfort and visualization of mediastinal structures, while maintaining spontaneous respiration.

The glossopharyngeal nerve block targets the afferent limb of the gag reflex. The intraoral approach was done by application of lidocaine 10% at the palatopharyngeal arch. The superior laryngeal block targets the structures above the vocal cords. The external approach was done by injecting 2mL of lidocaine 2% at the superior cornu of the thyroid cartilage. The recurrent laryngeal nerve innervates the vocal cords and trachea. Direct block of this nerve may result in vocal cord paralysis; thus, the translaryngeal approach is preferred. The cricothyroid membrane was identified then 2mL of lidocaine 2% was injected. Dexmedetomidine drip was also maintained to reduce additional sedative dosing and to minimize the risk of respiratory depression and hemodynamic instability.

However, these techniques require knowledge of airway anatomy and regional anesthesia. Additionally, these approaches carry a risk of complications, such as nerve injury and intravascular injection, which can be reduced with proper technique.

The Fontan procedure is the principal technique for surgical palliation of congenital heart defects involving a single functional ventricle. Patients with Fontan physiology are now surviving longer and presenting more frequently for non-cardiac surgery in adulthood. This case emphasises the benefits of regional anaesthesia in their management.

We report supraclavicular and intercostobrachial block for awake surgery in an adult with Fontan circulation who presented for emergency fixation of complex traumatic fractures of his radius, ulna and olecranon.

Fontan circulation allows non-pulsative blood from the systemic venous system return directly to the pulmonary arteries and then left atrium down a pressure gradient, with no active pumping of blood through the lungs. This is made possible by higher systemic venous pressures in the Fontan circulation than the atrium, creating a transpulmonary driving pressure. Maintaining CVP and optimising PVR are essential for maintaining pulmonary blood flow, venous return and CO. Regional anaesthesia is a beneficial alternative to GA for these patients. It is less likely to impact SVR, PVR and myocardial contractility, thus maintaining venous return and CO. Regional also maintains spontaneous ventilation, reducing intrathoracic pressures and promoting pulmonary blood flow compared to invasive ventilation. Regional prevents severe postoperative pain, reducing sympathetic drive and risk of myocardial ischaemia. Adequate analgesia facilitates normal respiration and minimises opioid use, reducing respiratory complications that can cause hypoxia, hypercarbia and acidosis which may increase PVR and reduce CO.

The benefits of regional anaesthesia should be carefully considered and prioritised in this group of patients where possible.

Traditionally, sacral nerve root block is performed under X-ray fluoroscopy, which presents both technical difficulties and disadvantages. This study evaluated S1 and S2 nerve root block on a sagittal view in plane approach on cadavers.

A single anesthesiologist completed ultrasound-guided bilateral S1/S2 nerve root block on six embalmed cadavers. Each cadaver was placed in a prone position. The convex probe was placed longitudinally, approximately 1–2 cm lateral to the midline, to identify the L5/S1 facet joint. The probe was moved caudally and the concavity on the posterior sacral surface corresponding to the S1 posterior sacral foramen was identified. The S2 posterior foramen was identified in the same straight line from the L5/S1 facet joint. The 20-gauge nerve block needle was then inserted in-plane from the cranial aspect of the probe (Figure #1). It was inserted through the posterior sacral foramina and 1 mL of the green and blue dye was injected at S1 and S2, respectively(Figure#2). After dissection, all injections were assessed for accuracy, classified as accurate if dye stained the target foramen or inaccurate if it did not. Additionally, the depth from skin to foramen were measured.This study protocol was approved by the Ethics Committee.

The injection accuracy rate was 100% (12/12) for both the S1 and S2 nerve root blocks. The mean±standard deviation depth was 46±0.6 mm for S1 and 38±0.5 mm for S2.

This cadaveric study suggests that ultrasound-guided sacral nerve root block can be performed with high accuracy using the sagittal view in plane approach.

Local anaesthetic systemic toxicity (LAST) is a rare but potentially life-threatening complication of local anaesthetic use, typically presenting within minutes of administration.

We present the case of a 59-year-old female who underwent an open repair of a radial fracture. She was of a normal BMI (68kg), with an unremarkable past medical history. No abnormalities were noted on routine pre-operative bloods, and her ECG displayed sinus rhythm with a normal QT interval.

An axially block was performed under ultrasound guidance using 10cc of 2% lignocaine and 5cc of 0.5% L-bupivacaine. A target-controlled infusion of propofol was commenced. On knife-to-skin, however, the patient reported discomfort. The case was thus converted to a general anaesthetic. Approximately 10 minutes following an uneventful induction (and 30 minutes post block performance) an episode of non-sustained (monomorphic) ventricular tachycardia (NSVT) was noted. This was followed by several further episodes of NSVT over the next 5 minutes, each lasting approximately 5 seconds, and without significant haemodynamic compromise. Intravenous administration of magnesium, metoprolol and amiodarone failed to terminate these episodes, which were increasing in both frequency and duration. 150ml of Intralipid® 20% was subsequently administered, and the patient immediately reverted to sinus rhythm. She was successfully extubated. No further arrhythmias were noted.

This case illustrates an atypical presentation of LAST, with a notable delay in the onset of clinical signs. It also emphasises the importance of careful monitoring of patients in receipt of local anaesthetic who undergo general anaesthesia and lack the ability to communicate potential early toxicity-related symptoms.

Cerebral Cavernomas are vascular malformations that occur in 0.1-0.5% of the population. Despite the highly variable natural history and symptomatic presentation, they all pose a significant concern: cerebral hemorrhage. Among several risk factors, including an inherited bleeding disorder, delivery presents as another crucial one.

A 29-year-old pregnant woman, previously diagnosed with 3 cerebellar cavernomas and Von Willebrand’s disease, was admitted for elective caesarian section at 39 weeks. The case required multidisciplinary planning between anesthesia, hematology, neurology and obstetrics. Considering the patient's space-occupying lesion stability and hemorrhagic risk, epidural anesthesia was proposed.

No changes were observed regarding clot factors and ratios. Blood typing and 1g tranexamic acid were accomplished before neuroaxial approach. While monitored following ASA standards, we proceeded with a lumbar epidural catheter. Here, 90mg of ropivacaine and 10mcg of sufentanil were administered, with a total volume of 13mL, achieving a sensitive block up to T4 level. The surgery and post operative period elapsed without any events and the woman was discharged at day 3 post-surgery.

Currently there is no consensus regarding anesthetic approach in cerebral cavernomas. Generally, hemorrhage prevention is the main goal, and so are sudden variations in intracranial pressure. Neuroaxial anesthesia emerges as a valid option in obstetrics, since it avoids airway manipulation and hemodynamic changes associated to general anesthesia. This case required careful management of a patient with high-risk conditions for intracranial hemorrhage. Epidural anesthesia proved to be a valid choice, avoiding such severe outcome.

Patients with transposition of the great vessels (TGV) corrected by the Senning procedure present significant anesthetic challenges during pregnancy due to altered cardiovascular physiology and increased risk of hemodynamic instability. Effective anesthetic management aims to minimize cardiac stress and avoid acute hemodynamic shifts. This case highlights the efficacy and safety of incremental epidural anesthesia as a tailored regional anesthesia technique in this high-risk obstetric population.

A 29-year-old pregnant patient with Senning-corrected TGV, right ventricular dilation, severe aortic insufficiency, and right pulmonary vein stenosis underwent elective cesarean section. Given the high WHO morbidity/mortality risk (20–30%), a multidisciplinary team devised an anesthetic plan emphasizing gradual regional anesthesia. After invasive arterial monitoring and a preload of 500 mL crystalloid, epidural anesthesia was performed at L1/L2 using incremental boluses of 0.75% ropivacaine (4 mL per bolus, total 16 mL) administered over 25 minutes.

Incremental epidural anesthesia successfully prevented acute hemodynamic fluctuations, maintaining stable intraoperative vitals. Phenylephrine (150 mcg) provided minimal vasopressor support. The procedure proceeded uneventfully, with no perioperative complications. Postoperatively, the patient was closely monitored in a Level 2 ICU before transfer to a general ward, experiencing an uncomplicated recovery.

Incremental epidural anesthesia is a safe and effective regional anesthetic technique for managing elective cesarean delivery in patients with complex congenital heart disease corrected by Senning procedure. This individualized approach significantly minimizes cardiovascular stress and volume shifts, optimizing maternal-fetal outcomes in high-risk obstetric populations.

Cesarean section (CS) is associated with moderate to severe postoperative pain. If intrathecal morphine is not used, fascial plane blocks, such as transversus abdominis plane or quadratus lumborum (QL) blocks, have the potential to improve analgesia following caesarean delivery [1]. The Quadro Iliac Plane (QIP) block is a novel regional anesthesia technique involving injection of the local anesthetic at the posterior aspect of the QL muscle, near its attachment to the inner surface of the iliac crest, in the inter-muscular plane between the erector spinae and QL muscles. [2] The QIP block enables effective blockade of the lower lumbar nerves, providing lumbo-sacral, abdominal, and hip analgesia. [3-7]

A 35-year-old female (ASA II, BMI 22.0) underwent an elective CS (Pfannenstiel incision) under spinal anesthesia (L1-L2 level, ropivacaine 10 mg). Aseptically, a single-shot bilateral ultrasound-guided QIP block was performed postoperatively, administering 0.2% ropivacaine 25 ml on each side. (Fig. 1) Intravenous paracetamol at fixed times (3 g per day) was prescribed as a standard measure with provision for rescue analgesia (intravenous ketorolac or tramadol if NRS > 5). Written informed consent was obtained from the patient for the anesthesia plan, block placement, and this report's publication.

After spinal anesthesia wore off, sensory testing revealed T10 to L4 dermatome coverage. Pain assessment (Numerical Rating Scale [NRS]) showed analgesia at rest and during movement: NRS 1/2 at 6 and 12 hours, peaking at 2/5 at 24 hours, and returning to 0/0 at 48 hours. No motor block or side effects were observed. Hemodynamic parameters remained stable. Rescue analgesia was required at 24 hours postoperatively (ketorolac 30 mg). Early mobilization was achieved at 8 hours, and full mobilization by 24 hours. No complications or side effects were recorded.

This case highlights the QIP block as an opioid-sparing technique providing effective postoperative analgesia in CS.

Breakage of epidural catheters is an unusual occurrence whose subsequent therapy lacks uniformity due to the absence of a consensus and defined standards. We present a rare complication of epidural catheter breakage with some resistance appeared during removal, without any neurological sequalae in 20 year old primigravida lady after normal vaginal delivery.

Immediately we send the patient to radiology department for lumbar x ray that could not show the missing catheter, so CT lumbar showing: The epidural catheter segment is seen passing through L1/2 interspinous level , its proximal segment coursing vertically upwards along the epidural space for 1.6 cm. Its distal end noted left off midline just deep to the prevertebral fascia, lying about 2 cm deep to the skin surface. Evidence of multiple air foci epidural and along the subcutaneous tissue of the back (recent post-epidural anesthesia). Neurosurgery consultation with successful removal of the breakage part under GA. The patient discharged home without any neurological deficit.

The management of epidural catheter breakage depends on: If the fragment is in the spinal canal: Surgical removal is often recommended, especially if the patient is experiencing symptoms like neurological deficits. If the fragment is outside the spinal canal: Conservative management: If the patient is asymptomatic and the fragment is not causing any issues. Surgical removal: This may be considered if there is a risk of infection or neurological complications, or if the patient is concerned about the retained fragment.

Management of a broken epidural catheter fragment depends on its location and the patient's symptoms. In our case the epidural catheter should be removed as the patient is concerned about this missing part as well as our protocol it is considered as foreign body with possible delayed complications that could affect patient's health.

Anesthetic safety in pregnant women is a constantly developing field, which is why anesthesiologists are put in difficulty when choosing the anesthetic method. Moreover, laparoscopic surgery is beginning to advance more and more compared to open surgery, providing multiple benefits such as early discharge from the hospital. The purpose of this case is to determine the safest way to administer anesthesia to a first-trimester pregnant patient undergoing laparoscopic cholecystectomy and also whether combined epidural and spinal anesthesia (CSE) is a feasible choice.

37-years old primiparous patient, in the first trimester of pregnancy diagnosed with acute calculous cholecystitis for which emergency surgical intervention is required. Laparoscopic cholecystectomy under combined spinal and epidural anesthesia (CSE) is decided.. The doses used were 12 mg hyperbaric bupivacaine 0.5% for spinal anesthesia and 16 ml ropivacaine 0.75% for epidural. The intra-abdominal pressure under which the intervention was performed was 10 mmHg. Postoperative analgesia consisted of Ropivacaine 0.2% continuously on the epidural catheter and paracetamol 1 g if required.

The postoperative analgesia provided was good, only one dose of paracetamol being required. PONV were not present. The patient was extremely satisfied because she was conscious during the surgery and interacted with the anesthetic and surgical team, this fact reducing her anxiety. Fetal Doppler ultrasound was performed both before and after surgery, which revealed no pathological changes. The patient is discharged after 24 hours from the hospital.

Laparoscopic surgery in regional anaesthesia is a feasible procedure in the first trimester of pregnancy. The advantages of neuraxial anesthesia compared to general anesthesia include: no airways manipulation, reduced PONV, a better postoperative analgesia with a minimum of drugs, a reduced risk of thromboembolic event and it is not harmful to the fetus. Our approach highlights a possible new gold standard for anesthetic technique in laparoscopic surgery in pregnant patients.

Thoracic aorta aneurysms carry a risk of serious adverse events, including dissection, rupture and death. Aortic dissection is often associated with episodes of acute hypertension. Physical and emotional stress in the peripartum may increase this risk.

A 27-year-old patient was admitted for an elective caesarian section at 37 weeks of gestation. She had a diagnosis of ventricular septal defect without hemodynamically significant shunt, thoracic aorta aneurysm, obesity (BMI 46 kg/m2) and chronic arterial hypertension. Preoperative assessment indicated features of anticipated difficult airway, and an echocardiography revealed significant aortic root dilation of 50mm (representing 8mm increase during pregnancy). A multidisciplinary team proposed elective caesarian section as delivery route under epidural anesthesia.

An arterial line was inserted before lumbar epidural catheter placement. Incremental epidural bolus totaling 10mL ropivacaine 0.75% were administered to achieve and maintain surgical anesthesia, with minimal hemodynamic impact. Intermittent bolus of esmolol (total 100mg) and labetalol (total 10mg) were used to achieve heart rate and blood pressure control, and the patient had an uneventful intra-operative period. Post-operative labetalol infusion and invasive blood pressure (BP) monitoring took place in level II post-anesthesia recovery area for 48h, with no adverse events. She was transferred to the ward and discharged home at 72h.

Society guidelines have defined high-risk features for thoracic aorta aneurysms, of which the absolute diameter, growth rate and location of the aneurysm are some. Aortic root involvement, in particular, carries a higher risk of adverse events. This case presented a unique challenge regarding possible hypertensive surges in a patient with congenital cardiopathy that would benefit from avoidance of abrupt hemodynamic changes. Invasive BP monitoring and slowly titrated epidural anesthesia allowed for control of the sympathetic response of noxious stimuli while also maintaining hemodynamic stability, offering a valuable option in the management of these patients.

Pregnancy in heart transplant recipients presents complex anesthetic and obstetric challenges, primarily due to cardiac denervation and altered physiological responses to labour. Despite increasing prevalence, evidence guiding management remains limited. This case highlights the importance of multidisciplinary coordination and individualized anesthetic planning to ensure maternal and fetal safety throughout labour and delivery.

A 36-year-old primigravida with a history of orthotopic heart transplantation five years earlier for dilated cardiomyopathy was carefully followed throughout pregnancy by a multidisciplinary team. Her care included tailored immunosuppressive therapy and trimesterly cardiology evaluations, with a recent (1-month-old) transthoracic echocardiogram with preserved biventricular function. At 37 weeks and 2 days of gestation, she presented to our center in spontaneous labour.

The patient presented with labour-related pain, was hemodynamically stable, with no signs of acute cardiac decompensation. Preeclampsia was diagnosed and magnesium sulfate was initiated. Given the underlying cardiac history, continuous monitoring was implemented, including 5-lead ECG and invasive arterial blood pressure, to enable early detection of potential cardiovascular instability. Preemptive epidural analgesia was initiated during early labour (2 cm of cervical dilation) using titrated ropivacaine 0.2% and a single 5 mcg bolus of sufentanil. This approach ensured effective analgesia and maternal comfort without compromising hemodynamic stability. During contractions, transient periods of hypotension were noted, but there was no need for vasoactive support. After 12 hours of labour, the patient had an uncomplicated spontaneous vaginal delivery of a live newborn weighing 2045 g. Postpartum care included continued invasive monitoring.

Heart-transplanted parturients require individualized anesthetic care prioritizing early neuraxial analgesia and continuous invasive monitoring to ensure hemodynamic stability and attenuate adrenergic response. Given their increased risk for complications such as arrhythmias, acute heart failure, and pre-eclampsia, prompt intervention and close monitoring is critical. This case highlights the pivotal role of anesthesiologists in optimizing care for this high-risk population.

Paresthesia,neuropathy during childbirth is very often a consequence of prolonged expulsion in primiparous women,where the second period of labor lasts longer and requires a certain position on the delivery table (lithotripsy position).During childbirth under epidural analgesia,postpartum neurological symptomatology is always directed towards anesthesia.

A 26- A 26-year-old primipara was admitted for delivery under epidural analgesia.Past medical hystory was remarkable.Epidural block was at the level of L3/L4 with epidural catheter placed without problems.After the test dose(Lidocaine 2% 3ml),continuous analgesia was started (0.10% Levobupivacaine with opioid adjuvant) and the dose was adjusted according to pain and hemodynamic parameters.During childbirth without neurological symptoms and active participation in childbirth.The birth lasted 7 hours, with the last 2 hours in the left semilateral position with bent legs for easier lowering of the baby.After 30 minutes of the birth,the catheter was removed without complications.When standing up for the first time, the patient complained of numbness in the left lower leg, inability to bend the leg and dorsiflexion of the foot.Neurological examination revealed left common peroneal nerve palsy-a positive Tinel’s sign in the left fibular head,numbness and paresthesia in the left lower leg from the lateral side to the dorsal foot,a drop foot.Polyvitamin therapy and early physical therapy was started immediately after the neurological examination.One month after giving birth,only mild weakness during dorsiflexion remained,which completely disappeared within three months.

Postpartum peripheral nerve injuries occur in approximately 0.3–2% of all deliveries.Here we have presented a very rare paresis of the peroneal nerve,only 1% during childbirth,which is a consequence of increased pressure on the lower legs and the peroneal nerve in the area of the head of the fibula during prolonged expulsion

This indicates that when a certain position is required during childbirth,it is necessary to rest the patient occasionally to avoid neurological symptoms especially during epidural analgesia.

Uterine atony (UA) is a medical condition where the uterus fails to contract effectively either after labor or cesarean section (CS). This can lead to postpartum hemorrhage (PPH), which can be life threatening. The present study describes a case of UA during CS that received spinal anesthesia (SA), that lead to acute hysterectomy. Most of the similar cases reported, converted the anesthesia from spinal to general (GA).

A 28 year old female underwent a selective CS due to previous CS. The patient's medical history was clear, and her pregnancy was uneventful. The patient was informed and consented to spinal anesthesia. A 25G pencil point spinal needle was used and the patient received a mixture of Ropivacaine 7.5% and Fentanyl. The operation until the baby's delivery was uneventful and the patient was stable. After the removal of the placenta, the patient presented a massive bleeding with subsequent hypotension and tachycardia. Uterine massage and uterine contraction medication did not produce any results, thus the gynecologists decided to proceed with an emergency hysterectomy. The patient was treated aggressively with liquids and vasopressors. Due to hemodynamic instability of the patient, it was decided to not convert to GA as the patient was fully alert and responsive and to avoid any futher hemodynamic fluctuations.

Despite her condition the patient did not manifest other symptoms apart from mild nausea and exhaustion feeling. She was calm and informed about the situation. SA did not cause any further hemodynamic instability. As soon as the uterus was removed, the bleeding ceased, vasopressors were no longer needed and the rest of the operation was uneventful.

While GA remains the most common choice for emergency hysterectomy, SA can be maintained in certain cases, especially if the patient is stable, and has no contraindications. However, it requires continuous careful assessment and management.

Hereditary angioedema (HA) requires careful management during pregnancy and cesarean section due to hormonal changes, trauma, infection, and fluid balance shifts. Tailored perioperative care is essential for pregnant HA patients.

A 23-year-old female with hereditary angioedema (HA) at 39 weeks of pregnancy underwent cesarean section. She had a family history of HA and experienced her first attack at age 10, with additional attacks in 2021 and 2024. She received C1-INH concentrate before a cesarean section in 2023. Preoperative consultation led to the administration of 1000 IU of C1-INH concentrate 2 hours before surgery for prophylaxis. C1-INH, 2 units of FFP (fresh frozen plasma), tranexamic acid were prepared for potential complications. Spinal anesthesia was performed, with difficult airway equipment available for potential laryngeal edema or conversion to general anesthesia. During surgery, the patient's vital signs remained stable. She was transferred to the ICU for 24-hour monitorization, no attacks occured.

Literature does not favor one anesthesia type over the other. Regional anesthesia was chosen to minimize fetal effects, with spinal anesthesia preferred for the short surgery. However, general anesthesia drugs and airway equipment were prepared due to potential intubation difficulties.

In patients with hereditary angioedema (HA) undergoing cesarean section, prophylaxis against potentially fatal angioedema attacks should be considered. Even with regional anesthesia, surgery may trigger attacks, so C1-INH concentrate, FFP, tranexamic acid should be prepared for treatment. As with all cesarean sections, general anesthesia preparations should be made, difficult intubation equipment and a cricothyroidotomy set should be available for potential laryngeal edema.

Epidural anaesthesia is the most common method of labor analgesia. As TikTok becomes an increasingly used source for health information, concerns have emerged about the accuracy and quality of its medical content. This study assesses the quality and engagement of TikTok videos on obstetric epidural anesthesia.

Using the keyword “epidural,” 100 TikTok videos were screened. Exclusion criteria included non-English, duplicates, unrelated topics, or primarily narrative (patient stories) or comedic (medical satire) content. Twenty videos met inclusion criteria. Two reviewers independently evaluated each video using mDISCERN, Global Quality Scale (GQS), and the PEMAT-AV tool. Engagement metrics and uploader background (physician vs. non-physician) were recorded. Inter-rater reliability was assessed with Cohen’s kappa and Pearson correlation.

Inter-rater agreement was fair for mDISCERN (κ = 0.225) and slight for GQS (κ = 0.021). Mean scores were low: mDISCERN = 2.25, GQS = 2.6, and PEMAT Total = 63.9%, reflecting poor overall educational quality. Videos averaged 1.1 million views, 68,469 likes, and 1,018 comments, yet engagement showed no correlation with quality. Notably, comment count negatively correlated with PEMAT scores (r = –0.44), suggesting more interactive videos may be less educational. Physician-created videos had higher GQS scores, while non-physicians scored better in understandability. Of 100 screened videos, 33 were narrative and 13 were comedic—excluded due to format—which may contribute to normalisation or trivialisation of the procedure.

Despite broad reach, TikTok videos on epidural anaesthesia demonstrate low educational quality. Given the platform’s influence, physicians must contribute accurate, high-quality content to counter misinformation and support informed decision-making.

Optimal dosing of intrathecal local anaesthetics and adjuvants like fentanyl and morphine can be influenced by patient-specific factors, particularly Body Mass Index (BMI). Furthermore, spinal-induced hypotension is a frequent complication, with vasopressor support often required. This audit aims 1. To assess spinal dosing practices (bupivacaine + adjuvants). 2. To evaluate BMI variations, block heights achieved and hemodynamic outcomes.

Prospective data collection. 30 patients(April–June 2025) undergoing caesarean under spinal anaesthesia. • BMI categorization, • Dose of 0.5% hyperbaric bupivacaine (ml), • Sensory block height before surgical draping, • Vasopressor use (yes/no) Standardized data sheets were filled.

The Body Mass Index (BMI) distribution: one patient (3.3%) was underweight (BMI <18.5), 12 patients (40%) had a normal BMI (18.5–24.9), five patients each (16.6%) fell into the overweight (25–29.9) and obese class I (30–34.9) categories, seven patients (23.3%) had a BMI of 35 and above. Dosing of bupivacaine: two patients (6.6%) received 1.8–2.0 ml, twelve patients (40%) received 2.1–2.2 ml, and fifteen patients (50%) received 2.3–2.5 ml, 1 case N/D. Below T6 level 1(3.3%), three patients (10%) between T5 and T6, and sixteen patients (53.3%) at the desired T4 level. Two patients (6.6%) had a block height higher than T4. However, in eight cases (26.6%), the sensory level was not documented. Vasopressor or inotrope use was recorded in twenty-one patients (70%), while the remaining nine patients (30%) did not require inotropes.

The audit highlights a tendency towards higher than recommended bupivacaine dosing, with significant vasopressor use, and inconsistencies in sensory level documentation.

Sedation for oocyte retrieval must provide effective analgesia without respiratory compromise or harm to embryo quality. We compared ketamine-propofol (Ketofol, KP) with ketamine-dexmedetomidine (Ketodex, KD), hypothesising that KD would match analgesia while reducing adverse effects and embryo quality.

: In a single-centre, open-label, randomised trial, 60 ASA I–II patients (20–40 y) were assigned to KP or KD (30 each). KP received propofol 1 mg kg⁻¹ + ketamine 0.5 mg kg⁻¹, then propofol 3 mg kg⁻¹ h⁻¹. KD received dexmedetomidine 1 µg kg⁻¹ over 10 min + ketamine 0.5 mg kg⁻¹, followed by dexmedetomidine 0.3 µg kg⁻¹ h⁻¹; both regimens included ketamine 0.5 mg kg⁻¹ h⁻¹. Primary outcome was cumulative pain; secondary outcomes were rescue-opioid use, apnoea, postoperative nausea-vomiting (PONV) and embryological indices.

Median pain scores remained ≤1 in both groups (p > 0.05). Rescue fentanyl was required in 0 % KD vs 60 % KP (p < 0.001). Apnoea occurred in 0 % KD vs 53 % KP (p < 0.0001). PONV at 30 min was 3 % KD vs 50 % KP (p < 0.0001). Fertilisation stayed at 100 % in both arms, while day-3 cleavage favoured KD (87 ± 18 % vs 78 ± 32 %). Haemodynamic variables, satisfaction scores and discharge readiness were comparable.

Ketodex offers analgesia equivalent to Ketofol yet virtually eliminates opioid need, respiratory depression and early PONV without compromising embryo development. KD is therefore a safe, embryo-friendly alternative for procedural sedation during IVF oocyte retrieval.

Labor neuraxial analgesia is the gold standard for labor pain management. However, variability in its effectiveness and management can compromise maternal satisfaction. This study assessed the impact of introducing quality improvement indicators (QIIs) to optimize obstetric anesthesia care.

We conducted audits to assess the quality of labor analgesia based on 3 QIIs: analgesia, expulsion, and maternal satisfaction, with 5 as the highest score. Cases with scores below 4 were investigated then we modified our practice accordingly. Secondary outcomes included epidural failure rate, dural puncture rate, and the incidence of conversion to general anesthesia for intrapartum cesarean section. Data were collected retrospectively over a 3-month pre-intervention and a 21-month intervention period.

We compared responses between 303 pre-intervention and 2,231 intervention cases. QII scores improved significantly, from a mean of 4.77 to 4.96 (p = 0.043). The percentage of maternal satisfaction scores below 4 decreased from 2.3% to 0.3% (p < 0.001). Progressive narrowing of the min–max gap and 95% CI suggests enhanced stability in analgesia quality over time. Epidural failure rates declined from 6.3% to 4.7% (p = 0.25), while dural puncture rates increased slightly from 0.0% to 0.45% (p = 0.38). General anesthesia conversion for category 1 cesarean section decreased from 100% to 33.3% (p = 0.25) but increased slightly from 3.0% to 5.2% (p = 0.72) for category 2-3 cases.

Conducting regular audits with subsequent practical changes led to improvement in analgesia quality and maternal satisfaction. These findings support the broader adoption of QII-driven frameworks in obstetric anesthesia.

Historically, it was common belief that childbirth should be painful, as quoted in Genesis: “In sorrow thou shalt bring forth children”. The first documented use of ether for labour in 1847 was met with societal criticism. It was only after Queen Victoria’s use of chloroform during childbirth in 1853 that labour analgesia met with growing acceptance. However, limitations included serious adverse effects including respiratory depression. Nitrous oxide was adopted in 1881, providing inhalational analgesia, albeit incomplete pain relief. In 1907, morphine and scopolamine were tried, but their favour rapidly declined due to adverse foetal outcomes and reduced maternal satisfaction due to amnesic effects.

In 1898, Bier described how cocainization of the spinal cord abolished lower abdominal pain. A year later, Kreis performed the first spinal anaesthesia in labour. Stoekel modified the technique, injecting in the caudal epidural space without dural penetration, limiting incidence of headaches. Aburel threaded a catheter through the caudal epidural space, allowing repeated injections for analgesia without needing to repeat the procedure. This approach was superseded by lumbar epidural by Hingson, who described preserved motor function with improved control of sympathectomy and extent of block.

Advancements continued in the late 20th century - discovery of safer and longer-acting amide local anaesthetics, exploitation of synergism using intrathecal opioids, refinements to the spinal needle tip and introduction of patient-controlled analgesia. Today, epidural analgesia remains the gold standard for labour pain.

The revolutionisation of labour analgesia by lumbar epidural arguably represents one of the greatest achievements of medicine in history.

In the 1800s, in Sweden and France, countries with the best maternal health today, nearly 1 in 100 women died from childbirth. Major causes included haemorrhage and sepsis. Traditionally, caesaren section was a post-mortem practice. Today, in many developed countries, it represents the commonest major abdominal surgery in young adults.

Historically, general anaesthesia was primarily used for caesareans. However, concerning reports of anaesthesia-related complications emerged in 1951, mainly pulmonary aspiration, difficult intubations and hypoxic injury. In 1764, Magendie described the presence of nerves surrounded by fluid circulating around the brain and spinal cord, contributing to pain and movement. In 1898, Bier described total lower body numbness following intrathecal injection of cocaine. Development of pencil-point needle tips limiting post-spinal headaches and ability to remain conscious led to improved maternal satisfaction and acceptance with spinal anaesthesia.

General anaesthesia has been superseded by spinal anaesthesia, accounting for only 6% of caesareans in 2011, versus 35% in 1980. The safer provision of anaesthesia during caesarean has given rise to its soaring incidence worldwide. Whilst maternal and healthcare professional attitudes have contributed in the elective setting, medical indications remain significant, including life-threatening maternal and foetal conditions, allowing millions of women and babies to survive childbirth.

Today, maternal mortality rates are lowest (3-4 per 100,000) in developed countries. High mortality rates remain in countries with poor access to anaesthesia providers and operative facilities. While spinal anaesthesia has permitted safer caesareans, future efforts need to be made to improve the availability of obstetrics anaesthesia in developing countries.

Spinal anesthesia is the preferred method for elective cesarean sections due to its safety and efficacy profile. While ropivacaine is widely used in Greece, recent developments in preservative-free formulations of chloroprocaine have revived interest in its spinal application. This study aimed to compare the onset, duration, and safety profile of spinal chloroprocaine 1% versus ropivacaine 0.75% in women undergoing elective cesarean section

This is an interim analysis of a prospective, randomized, single-blind study in parturients subjected to elective cesarean section under combined spinal-epidural anesthesia. Participants were allocated to group C, receiving 3.8 ml chloroprocaine 1% plus 10 µg fentanyl and Group R, receiving 1.8 ml ropivacaine 0.75% plus 10 µg fentanyl via the spinal route. The primary endpoints of this study include the onset and duration of sensory and motor blockade following intrathecal administration of either chloroprocaine or ropivacaine. Additional maternal and neonatal outcomes were also evaluated

The required time to achieve a T4 sensory block or a full motor block (Bromage 3) was no different between groups (p=0.459 and 0.360, respectively). However, group C presented with a significantly shorter sensory block duration (84.5±15.6 vs. 124.8±14.6, p<0.001) as well as motor block duration (71.5±13.1 vs. 96.3±20.7, p<0.001). Other outcomes were comparable

Preliminary findings suggest that spinal chloroprocaine provides a faster recovery profile compared to ropivacaine, with comparable safety outcomes for both the mother and neonate. These characteristics may render chloroprocaine a viable alternative in obstetric anesthesia, particularly in settings requiring rapid offset of block and quick mobilization of the parturient

Subarachnoid block (SAB) is commonest method for caesarean section (CS). Conventionally, opioids are mixed with hyperbaric bupivacaine in a single syringe before administration. Sequential technique involves administration of these drugs via separate syringes. Significant hypotension is caused after SAB, however, Sequential technique has been shown to cause less hypotension.

A Prospective Randomized Interventional Comparative study was done with 180 parturients for 18 months undergoing elective CS under SAB. The participants were randomized by computer generated sequence into two groups of 90 each, group M and S. Group M (mixture) received 0.5% hyperbaric bupivacaine 9 mg (1.8 ml) with fentanyl 15 mcg (0.3 ml) in a single syringe, while S (sequential) received both drugs in separate syringes. The objective of the study was to test the efficacy of SAB in by block characteristics, hemodynamics and time to achieve sensory block height (T5).

The study showed that Parturients in group S had higher level of sensory block & high modified Bromage score (MBS) than in group M. The median time to achieve T5 level in group S was less. The median sensory block duration of patients in group S was longer. The difference between two groups was highly significant. The mean time of two segment regression of block was longer in group S.

The study concluded that sequential technique of giving drugs for SAB in C- section reduces the time to achieve complete sensory and motor block and delays block regression. Incidence of hypotension was low in both the groups.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity worldwide. Although several perinatal risk factors have been identified, the influence of oxytocin dosage on PPH development remains unclear. This study aimed to investigate perinatal risk factors for PPH, with particular attention to oxytocin administration and its association with blood loss and hemoglobin decline.

A retrospective cohort study was conducted at Westpfalz Hospital Kaiserslautern, including all deliveries between December 1, 2022, and May 31, 2023. Pregnant women aged under 50 years were eligible. Data collection encompassed demographics, preoperative hemoglobin, estimated blood loss, total oxytocin dose, and comorbidities. Patients were categorized into three groups: no PPH (<500 mL), PPH (>500 mL), and severe PPH (>1000 mL).

A total of 460 patients were included. The incidence of PPH (>500 mL) was 28.5%, and severe PPH (>1000 mL) occurred in 9.5%. Mode of delivery emerged as the only independent risk factor for PPH, while dependent factors included maternal age, BMI, ASA classification, preoperative anemia, induction method, and previous cesarean section. Importantly, administration of ≥15 IU of oxytocin was statistically significantly associated with greater estimated blood loss and a larger hemoglobin drop (mean blood loss 914 mL vs. 422 mL; mean ΔHb 2.8 vs. 1.8; p < 0.01).

Our findings suggest that a cumulative oxytocin dose exceeding 15 IU may contribute to uterine atony through receptor desensitization, potentially worsening blood loss. Prospective research is needed to establish optimal oxytocin dosing strategies and guide timely escalation to second-line uterotonics.

Neuraxial anaesthesia is the preferred technique for caesarean delivery (CD), yet intraoperative pain during CD (PDCD) remains a significant concern. PDCD is distressing for patients and a major cause of litigation in obstetric anaesthesia [1,2]. The Royal College of Anaesthetists (RCoA) recommends PDCD rates below 5% for category 4, <15% for category 2–3, and <20% for category 1 CDs [3].

A retrospective review was conducted of 3,419 CDs performed at the Rotunda Hospital in 2024. Anaesthetic records were screened for documented intraoperative pain. Data on CD category, anaesthetic technique, pain timing, and conversion to GA were collected. Audit standards followed RCoA guidance [3].

PDCD incidence was 3.8% (133/3419). GA conversion occurred in 33.8% of these cases. PDCD was slightly more common in emergency CDs (4.1%) than elective (3.6%) [4]. Rates by anaesthetic technique were: spinal 3.8%, epidural top-up 4.6%, and CSE 12% (Table 1) [5]. Most PDCD (66%) occurred after delivery (Table 2; Figure 2). IV fentanyl was the most frequent intervention (53%) [6]. The distribution of anaesthetic modalities among PDCD patients is shown in Figure 1.

PDCD rates at the Rotunda Hospital are within recommended thresholds [3]. However, the increased incidence with CSE and predominance of late-stage pain suggest areas for targeted improvement. Structured documentation and tailored intraoperative pain management remain key to optimising outcomes [1,6].

Placenta accreta spectrum (PAS) is a group of conditions that describes the morbid attachment of the placenta to the uterine wall. These disorders pose significant risks due to associated massive haemorrhage, coagulopathy, end-organ dysfunction and death(1). According to figures from the Royal College of Obstetricians and Gynaecologists, the incidence of PAS ranges from 1-300 to 1–2000 pregnancies.

This retrospective case series examines the management of 23patients with PAS over 5years from 2019-2024 at a tertiary referral centre, with a focus on anaesthetic strategies and outcomes using electronic patient records

PAS subtypes included accreta(52%), increta(9%), and percreta(39%). Most cases(91%) were managed with a pre-planned MDT approach involving obstetricians, anaesthetists, interventional radiologists, neonatologists, and other relevant specialists. 74% of deliveries were elective. All cases were managed in an interventional radiology (IR) theatre, with prophylactic aortic balloon catheter placement. Regional anaesthesia was used initially in all patients (epidural 70%, combined-spinal-epidural 30%), followed by general anaesthesia. TIVA was preferred in 61% of cases. Mean blood loss was 2065mL (range 700–7000mL). Hysterectomy was required in 86% of cases (30% total, 56% subtotal), but three(14%) patients avoided hysterectomy. Only two(9%) patients required postoperative critical-care admission with only one requiring level three care. There was no maternal mortality.

This case series highlights that with detailed MDT planning, interventional radiology, and tailored anaesthetic management, PAS can be managed safely with favourable outcomes. Low critical care admission rates and the possibility of uterine preservation in selected cases reflect the benefits of a structured, specialist-led approach in a tertiary setting.

Immune thrombocytopenic purpura (ITP) during pregnancy presents significant challenges for labour analgesia and anaesthetic planning. We report the peripartum management of a parturient with chronic steroid-resistant ITP and a nadir platelet count of 13×10⁹/L during pregnancy, associated with mucocutaneous bleeding.

A 32-year-old primigravida at 38 weeks, with a baseline platelet count of 40 × 10⁹/L, was admitted for platelet optimisation and planned induction of labour. She had received three IVIG cycles during pregnancy. Although platelet counts typically rose above 100×10⁹/L by day three post-infusion, they declined below 50×10⁹/L within a few days. A multidisciplinary team involving obstetrics, anaesthesia, haematology, and transfusion medicine advised targeting a platelet count >80 × 10⁹/L to allow neuraxial analgesia and vaginal delivery if feasible, ensuring platelet availability throughout labour.

On day 5 of admission, platelet count rose to 117×10⁹/L following a fourth IVIG cycle, allowing induction of labour. Epidural analgesia was safely performed in a single, uncomplicated attempt, with platelet levels above target and no bleeding diathesis. Labour progressed spontaneously but required instrumental delivery (forceps) due to arrest of descent. Estimated blood loss was 300 mL. The epidural catheter was removed postpartum with platelet count at 115×10⁹/L., and analgesia transitioned to intravenous. The patient remained stable. No bleeding or neurological complications occurred. Neonatal outcome was favourable (Apgar 9/10/10).

This case supports the feasibility and safety of neuraxial analgesia in selected parturients with ITP, highlighting the importance of multidisciplinary coordination, close haematological monitoring, and timely intervention. Individualised assessment remains essential to optimise safety in thrombocytopenic pregnancies.

Epidural anesthesia is a widely and generally safe technique during labor. A rare complication is Horner’s syndrome (HS), characterized by miosis, ptosis, and facial anhidrosis, resulting from blockade of sympathetic C8-T1 preganglionic fibers. Proposed mechanisms include increased sensitivity to local anesthetics (LA) during pregnancy, cephalad spread of LA during labor, and inadvertent subdural catheter placement, which can result in an unpredictable sensory block with minimal motor block.

A 158 cm tall parturient with an epidural catheter in place undergoing an urgent cesarean received a 14 mL bolus of 0.75% ropivacaine with 10 mcg sufentanil (2 mL). Anesthetic conditions were inadequate for surgery, prompting sedation with propofol and ketamine. Symmetry and sensory level were not documented at this time.

Later in the PACU, the patient developed ptosis, miosis, and facial anhidrosis, along with mild upper limb paresthesias. She reported a VAS score of 0 at the surgical site, denied pain, and exhibited no signs of motor blockade. Symptoms resolved spontaneously within two hours, and a 2 mL/h ropivacaine elastomeric pump was started. Thirty minutes later, the patient reported numbness and weakness in the lower limbs. Catheter aspiration was negative for cerebrospinal fluid or blood, and the catheter was removed intact.

HS is rare following epidural anesthesia, most commonly occurring in parturients undergoing cesarean delivery. Although the exact mechanism is unclear, a subdural block was the likely cause in this case. Most cases are benign and resolve spontaneously, but rare and potentially fatal complications should be considered.

Pregnancy in women with macroprolactinomas poses significant anesthetic and obstetric challenges due to the risk of tumor enlargement, potentially causing headaches or visual field deficits. Cesarean delivery under neuraxial anesthesia in such patients is rarely documented. Anesthetic management must ensure hemodynamic stability while maintaining close neurological monitoring, as acute deterioration may necessitate urgent neurosurgical intervention.

We present the case of a 30-year-old woman, G4P2, with a macroprolactinoma managed throughout pregnancy with bromocriptine and hydrocortisone. She had undergone two previous cesarean sections: one under neuraxial anesthesia and one under general anesthesia due to presumed intracranial hypertension. A recent MRI revealed an increased tumor volume without signs of intracranial pressure. There were no other significant comorbidities. 

At 38 weeks, the patient presented for elective cesarean section. A thorough neurologic assessment was performed, with no signs of intracranial hypertension, headache, or visual field changes. Upon admission, she received stress-dose corticosteroid coverage with intravenous hydrocortisone, and routine blood tests revealed no significant abnormalities. Standard ASA monitoring was implemented, with heightened vigilance for any acute neurological changes. Combined spinal-epidural block was performed with intrathecal sufentanil and ropivacaine by the most experienced anesthesiologist. Hemodynamic stability was meticulously maintained to prevent hypotension and ensure adequate pituitary perfusion. The procedure proceeded without complications, and a live newborn weighing 3000 g was delivered. Postoperative care was uneventful.

This case emphasizes the role of anesthesiologists in managing neuroendocrine complications during pregnancy. Neuraxial anesthesia, when carefully planned and executed, may offer a safe option.

Loeys-Dietz syndrome (LDS) is a rare autosomal dominant connective tissue disorder characterized by arterial aneurysms, marfanoid habitus, and ligamentous laxity. In pregnancy, cesarean delivery is recommended for patients with significant aortic root dilation (>4.0 cm) or a family history of aortic dissection. Anesthetic management is challenging due to vascular and anatomical abnormalities, and the choice between neuraxial and general anesthesia must be individualized.

We report a 37-year-old woman with genetically confirmed LDS (TGFBR1 mutation), scheduled for her second elective cesarean. Her previous cesarean was under general anesthesia. Pregnancy follow-up included cardiology and high-risk obstetrics. Imaging revealed only mild ascending aortic ectasia (sinotubular junction ~40 mm), stable throughout gestation. She had a history of asthma and prior bilateral pleurodesis. Family history included sudden deaths likely due to aortic dissection. After multidisciplinary evaluation, neuraxial anesthesia was chosen due to stable imaging, pulmonary comorbidities, and the potential risks of hypertensive episodes with general anesthesia.

A combined spinal-epidural block was performed with intrathecal sufentanil and ropivacaine. The procedure was uneventful; mean arterial pressures remained between 65–80 mmHg. Analgesia and uterotonic protocols were standard. No complications occurred. The decision was supported by literature noting the risks of general anesthesia in LDS (e.g., hypertensive response to intubation, airway management). Neuraxial techniques avoid airway manipulation and promote hemodynamic stability, though caution is warranted due to theoretical risks like dural fragility. In this case, normal spinal MRI reduced such concerns.

Neuraxial anesthesia may be preferable in LDS patients, provided thorough evaluation and expert management are ensured.

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.

Laparoscopic bowel resection is typically performed under general anesthesia (GA), but adjunctive low-dose spinal anesthesia (LSA) may offer superior perioperative analgesia and reduce opioid requirements, potentially enhancing postoperative recovery. This study aimed to compare standard GA with GA plus LSA in terms of perioperative opioid consumption and pain control for patients undergoing laparoscopic bowel resection.

We conducted an observational study of 26 consecutive patients undergoing laparoscopic bowel resection at our institution between August and December 2024. Institutional ethical approval was obtained. Patients were divided into two groups: those receiving standard GA with intraoperative fentanyl and peripheral analgesics (n=20), and those receiving GA combined with LSA with intrathecal bupivacaine (7.5 mg) and fentanyl (25 mcg) (n=6). Both groups received postoperative analgesia with piritramide PCA, paracetamol, and metamizole. In the post-anesthesia care unit (PACU), mean Visual Analog Scale (VAS) pain scores and piritramide consumption were analyzed. Postoperative outcomes—including daily average VAS, piritramide bolus requests, and complications (PONV, pruritus, ileus)—were monitored for two days. Statistical analysis was performed using Python, employing t-tests for normally distributed data and Mann-Whitney U tests for non-parametric data.

Demographic characteristics and procedure duration were comparable between groups. The GA plus LSA group demonstrated significantly lower mean VAS scores (p=0.007) and reduced piritramide consumption (p=0.007) in the PACU. On the second postoperative day, the GA plus LSA group required fewer piritramide boluses (p=0.001). There were no significant differences in complication rates.

Combining GA with low-dose spinal anesthesia significantly reduces perioperative opioid consumption and pain scores in laparoscopic bowel resection, with no increase in complications. These findings suggest a potential role for combined anesthesia in optimizing postoperative outcomes, but larger, prospective studies are warranted to confirm and extend these results.

To evaluate the efficacy and security of the interscalene catheter for the rehabilitation of the stiff shoulder after arthoscopic surgery.

We performed a prospective review of serie of cases undergoing arthroscopic shoulder surgery for shoulder stiffness. An interscalene catheter was placed preoperatively to facilitate early, pain-free physiotherapy. Postoperatively, a continuous infusion of levobupivacaine 0.125% at 2 mL/h was maintained. Prior to each physiotherapy session, a 10 mL bolus of lidocaine 2% was administered through the catheter. Follow-up was conducted during hospitalization until hospital discharge through patient interviews and clinical evaluation of the block. Patient satisfaction was evaluated using a 1-to-10 numerical rating scale.

4 patients were included. Bolus of lidocaine 2% achieved full sensory and motor blockade allowing effective analgesia during rehabilitation. The average patient satisfaction score was 8 out of 10. No complications related to the catheter or anesthetic technique were observed. All patients were discharged between 48 and 72 hours after surgery.

The use of an interscalene catheter in the postoperative recovery is safe and enables active physiotherapy without pain, potentially reducing the risk of persistent stiffness and improving functional outcomes.

With its rising global prevalence, increasing numbers of patients with morbid obesity are undergoing a wide variety of elective and emergency surgery. Bariatric anesthesia and analgesia research and enhanced recovery after surgery(ERAS) have emphasized the need for protocol standardization and implementation. Especially, in moderate to severe OSA, an opioid- centric approach to pain management in the perioperative period should be avoided to avoid the dose dependent decrease in arousal and the increase in airway obstruction. Ultrasound guided erector spinae block is reported to lead to an analgesic effect on somatic and visceral pain in laparoscopic abdominal surgeries .

- Epidural injection group (Group E, n=100): Patient in this group will receive a dose of 25 ml bupivacaine 0.25% in the epidural space. The patient is placed in the sitting position. Identification of intervertebral spaces by palpation. Injection is made at the level of L2-L3 OR L4-L5. - Erectro spinae group (Group S, n=100): Patients in this group will receive a dose of 15 ml bupivacaine 0.5% + 5 ml normal saline on each side. after selecting the target transverse process for nerve block, place the US transducer in a paramediane sagittal orientation, approximately 2 cm from the midline ( spinous process) and try to visualize the transverse process.

there was a significant difference in the interval time before the call for a rescue analgesia between the two groups, with an average of 6 hours in the epidural group patients, and immediately after recovery for almost all the erector spinae group patient.

single epidural injection preoperatively is an effective method for control of post laparoscopic bariatric surgery pain

Effective pain control is essential for patients undergoing hip surgery. Superior cluneal nerve block (SCNB) and thoracolumbar fascia block (TLFB) offer promising options for postoperative analgesia.

We report a case series on the effectiveness of SCNB and TLFB in managing postoperative pain in patients undergoing hip surgery (total hip replacement, Proximal Femoral Nail Antirotation, and hemiarthroplasty).

This case series describes twelve patients receiving SCNB and TLFB with ropivacaine 0.375% and dexamethasone for postoperative pain control. All patients reported significant pain relief (most NRS 0-1 at rest and 0-3 during mobilization) and showed improved recovery without complications.

SCNB and TLFB are effective and safe options for postoperative pain management in patients undergoing hip surgery, enhancing recovery and reducing opioid use.

The Perioperative Pain Service (POPS) at Hospital for Special Surgery (HSS) is a multidisciplinary team specializing in pain management of orthopedic surgical patients. Under POPS, the Chronic/Complex pain service (CPS) identifies patients at high-risk for severe postoperative pain and opioid related adverse events before surgery, and devises personalized pain management plans, while the Acute Pain Service (APS) is an inpatient team that places and manages patient-controlled analgesia (PCA) when in response to 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 Hip Arthroplasty (THA) with and without POPS involvement.

After IRB approval, adult patients undergoing unilateral total hip arthroplasty receiving neuraxial anesthesia with and without peripheral nerve blocks 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 12,637 THA 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).

Acute pain trajectories after THA 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 after THA. Studies are underway to evaluate the impact of peripheral nerve blocks on these trajectories.

Open cholecystectomy surgeries are one of the painful surgeries on the upper abdominal region that requires multimodal analgesia for rapid patient recovery. Though the gold standard is using ultrasound, when assigned in areas with austere set-up, knowing anatomic landmark techniques could benefit the patient. Local infiltration analgesia can be an alternative if the team does not know nerve block techniques. Combining anatomic landmark and the cocktail used for LIA is the basis of this report. 5 patients were enrolled during one of my surgical mission trip where ultrasound is not availavle in the hospital.

The patients were apprised and only those who consented were included. Patients were inducted under spinal anesthesia with 4cc of 0.5% Bupivacaine. Once returned to supine position, subcostal transabdominis plane along the anterior axillary line was identified using a 2.5cm G23 syringe needle, 2 pops were noted from the external oblique and internal oblique fascial layer. LIA solution made of 20cc 0.3%ropivacaine with 30mg ketorolac, 100mg tramadol, 5mg dexamethasone and 0.2mg epinephrine was used for infiltration.

Patients were assessed prior to discharge from the recovery room. None of the 5 patients complained of pain at PACU. 24hours after surgery, patients were noted to be walking with no loss of appetite and analgesics taken were only oral paracetamol 1gram every 8hrs and celecoxib 200mg every 12hours. 48hours after surgery, patient was already discharged well with controlled pain of 1-2.

In the absence of technology, our knowledge of nerve block techniques should allow us to give its benefits towards our patient. While having an ultrasound also should aide us in honing our skills in anatomic landmarking which is very helpful in time when technology fails or is absent.

Scalp blocks are pivotal in facilitating patient comfort and analgesia during awake craniotomy procedures. This study aimed to compare the analgesic efficacy and safety of dexmedetomidine versus ketamine as adjuvants to 0.5% ropivacaine for scalp block. We hypothesised that ketamine, administered at a dose of 0.5 mg/kg, would demonstrate non-inferiority to dexmedetomidine in prolonging the duration of analgesia and enhancing postoperative pain management in awake craniotomy surgery for brain tumours. The primary outcome was time to first rescue analgesia (NRS ≥4). Secondary outcomes included onset of sensory block, intraoperative haemodynamics, sedation scores (RASS), postoperative pain scores (NRS), PACU discharge time, total 24-hour analgesic requirement, and incidence of adverse events.

This was a prospective, randomised, double-blinded, interventional trial conducted in 46 adult patients undergoing elective awake craniotomy. After institute ethical clearance (IEC/INT/2023/MD-1323) and CTRI Registration (CTRI/2024/01/061259), patients were allocated into two groups: Group RD (ropivacaine 0.5% + dexmedetomidine 1 µg/kg) and Group RK (ropivacaine 0.5% + ketamine 0.5 mg/kg). The Scalp Block was given by the landmark technique.

The median duration of analgesia was significantly longer in Group RK (18.67 hours) compared to Group RD (14.67 hours; p < 0.001). Sensory block onset was similar in both groups (p = 0.906). Group RK demonstrated higher intraoperative blood pressures, while Group RD had a higher incidence of respiratory depression (39.1% vs 8.7%; p = 0.016). No significant differences were noted in sedation depth, incidence of psychosis, hypotension, bradycardia, or PONV. Group RK had a longer PACU stay (p = 0.015).

Ketamine (0.5 mg/kg) is not inferior to dexmedetomidine (1 µg/kg) as an adjuvant to ropivacaine 0.5% for scalp block in awake craniotomy. It provides prolonged postoperative analgesia with a lower risk of respiratory depression, making it a viable alternative in clinical practice.

Rectus sheath block (RSB) is moderately recommended in ERAS protocols for colorectal surgery. It is a simple and effective technique, easily incorporated into clinical practice. As an alternative to opioids, RSB helps reduce the incidence of postoperative nausea and vomiting (PONV) and ileus—key concerns in elderly patients. This case illustrates the benefits of regional analgesia over systemic opioids in an emergency surgical setting in a geriatric patient.

A 92-year-old female patient with personal history of ischemic heart disease, arterial hypertension and pacemaker placement due to bifascicular blockade underwent an emergency exploratory laparotomy for short bowel syndrome, following prior elective bowel resection with terminal ileostomy for colon cancer. During the surgery an ileo-ileal anastomosis was performed under total intravenous general anesthesia. Postoperative pain management started intraoperatively with paracetamol, metamizol and tramadol administration and followed a multimodal approach, including ultrasound-guided bilateral rectus sheath block with 20 ml of 0.2% ropivacaine.

The patient achieved effective pain control without requiring systemic opioids neither in the post-anesthesia care unit nor throughout the postoperative period. Early oral intake and mobilization were possible, and no signs of postoperative ileus or PONV were observed. There were no complications related to the regional block.

In frail and elderly patients undergoing emergency colorectal surgery, analgesia using regional techniques such as RSB can significantly enhance recovery by minimizing gastrointestinal complications and opioid-related side effects. In this patient, considering the personal history of cardiovascular disease combined with the mortality associated with emergent laparotomies, makes cardiac stress reduction offered by regional analgesia even more relevant. This case supports the feasibility and clinical benefit of RSB in elderly patients, highlighting its safety and positive impact on recovery when used as part of a multimodal analgesic approach.

Amputation patients commonly suffer from chronic ischemic limb pain followed by immediate moderate to severe postoperative pain. The aim of this study was to compare pain management strategies that replace opioids and evaluate their effectiveness, advantages, and limitations.

In a randomised prospective study 58 patients undergoing above the knee amputation due to vascular disease were enrolled and randomized into two groups : spinal (SA; n=30) or general anesthesia (GA; n=28). Afterward, six subgroups were compared : suprainguinal fascia iliaca block (sFIB), epidural analgesia (EA) or esketamine i/v infusion (esKET) for the first 24 hours. All patients received multimodal analgesics. The primary outcomes were postoperative pain intensity (NRS scale); secondary - opioid consumption and incidence of breakthrough pain (NRS>7) in the first 24 hours.

Pain intensity in the first 24 hours postoperatively was observed as low to moderate (NRS 0-6). We found no significant difference in opioid (fentanyl, mean dose 40mcg/h) consumption between groups received SA versus GA. Totally 13.7% (8 / 58) of patients received opioids in the first 6-12 hours after surgery due to breakthrough pain, most of whom were in SA group + sFIB. Noneone with EA or esKET experienced brakthrough pain. All patients were observed in ICU for the first 24 hours.

Perioperative pain management after lower limb amputation is indeed complex and challenging. Our applied analgesia methods in the context of multimodal approach were not equally effective demonstrating higher incidence of breakthrough pain and need for opioids in spinal anesthesia group combined with fascia iliaca block.

Traditionally lung surgery is among the most painful surgeries in terms of post operative pain. In recent years, minimally invasive techniques such as VATS and RATS have improved the post op pain profile. However, pain after lung surgery still requires attention as uncontrolled pain is not only a negative experience for the patient but can result in respiratory complications. Aims: To audit current postoperative pain management (analgesics, dosing, pain score and physiotherapy engagement) in RATS at our institution, where RATS has been employed for a year. With established protocols for open thoracotomy and VATS and none for RATS, this audit aims were to use the current practices to guide a new RATS-specific pain management protocol.

We obtained date for a period of 1 year. During this time 42 patients underwent RATS. We reviewed the patients’ notes and drugs' kardex retrospectively. The data was collected in an anonymized manner.

Among 42 patients, 88.1% received regional/ neuraxial anaesthesia perioperatively. Postoperatively, 95.2% were initiated on PCA opioids, with 4.7% receiving oral opioids as needed. Postoperative day 1, 66.7% reported mild pain (PS 1-3), 28.6% experienced moderate pain (PS 4-6), and 4.76% had severe pain (PS > 7). All patients received paracetamol as part of multimodal analgesia, and 85.7% were prescribed NSAIDs. After PCA discontinuation, 40% transitioned to oral oxycodone and 57.1% to tapentadol. Active physiotherapy participation (66.67%) suggested effective pain control and recovery.

The audit demonstrates effective postoperative pain control within the current practice, with regional anaesthesia, PCA opioids, and multimodal analgesia (Paracetamol/ NSAIDs) integral to patient recovery. To standardize care, it is recommended to prescribe oral oxycodone universally post-PCA discontinuation, replacing the current mixed-protocol approach.

Rebound pain is an increasingly recognized phenomenon following peripheral nerve blocks, marked by a sudden and intense return of pain as the block resolves. While extensively studied in elective orthopedic procedures, its relevance to patients with blast injuries remains unclear. Blast trauma presents a unique challenge due to the combination of high-energy soft tissue injury, nerve damage, and complex inflammatory responses. This review aims to evaluate whether rebound pain constitutes a true clinical issue in this population or is merely a theoretical construct extrapolated from other contexts.

A narrative review of existing literature was performed to explore the pathophysiological basis of rebound pain, its reported prevalence in trauma patients, and its possible impact in the setting of blast injuries. Data from military medicine, high-energy civilian trauma, and regional anesthesia research were examined.

Although direct evidence in blast injury patients is lacking, several mechanisms—central sensitization, neuroinflammation, and abrupt reactivation of nociceptive pathways—may contribute to an exaggerated pain response following block resolution. Indirect reports from combat casualty care and trauma centers suggest that rebound pain may occur more frequently than documented, potentially leading to misinterpretation as inadequate anesthesia or undertreatment. This may result in excessive opioid use and delayed rehabilitation.

Rebound pain may represent a significant but under-recognized challenge in the management of blast trauma. Understanding its mechanisms and anticipating its occurrence are essential for effective analgesia. Implementation of multimodal pain strategies, proactive transition planning, and patient education may reduce its impact and improve outcomes. Further prospective studies are needed to confirm the incidence and clinical relevance of rebound pain in this unique and vulnerable patient group.

Effective postoperative pain management is vital for recovery, especially after major abdominal surgeries like open nephrectomy. The quadratus lumborum block (QL) is a promising regional anaesthesia technique that targets somatic and visceral pain pathways.

We report a 62-year-old Filipino, female, who underwent open nephrectomy, left, under general anaesthesia. Following induction and endotracheal intubation, an ultrasound guided QL block was performed with 20 mL of 0.3% ropivacaine while the patient was on right decubitus position. During intraop, no additional opioids were required to maintain surgical anaesthesia. The procedure was uneventful with no complications. Postoperatively, at 0, 1, 2, 3 and 6 hour, the patient reported a numeric pain score of 0 and demonstrated excellent recovery, including the ability to sit and ambulate comfortably on the same day. No additional opioids was necessary during the 24h postoperative period. The patient resumed activities early and was discharged on postoperative day 5 with completed antibiotics and without complications.

This case highlights the efficacy of the QL block in managing postoperative pain for open nephrectomy. The use of 0.3% ropivacaine ensured adequate pain relief and facilitated early mobilization, while avoiding common opioid-related side effects such as nausea and vomiting , pruritus, sedation, ileus and among others.

The QL block is a safe and effective option for postoperative pain control in open nephrectomy, promoting enhanced recovery. Further research may support its broader application in other abdominal surgeries.

This is a case report of a 79 year old male, ASA 4 patient with infected and occluded fem distal graft needing emergency surgery. He was septic with psudomonas infected groin wound, drowsy with renal impairment and other comorbidities. The neuraxial block like combined spinal epidural was risky due to his coagulation and septic status. Post operative pain management was also very challenging in his case.

The planned surgery was graft removal and ligation of artery and possibly Above Knee amputation. Renal impairment and need for prolonged surgical time needed prolonged anesthesia and analgesia as well. The patient was consented for an ultrasound guided psoas compartment block explaining the risks and benefits. It was performed safely using 30 ml 0.25% levobupivacaine with adrenaline and a psoas compartment catheter was inserted. Perioperatively patient had a sciatic nerve block as well to provide omplete analgesia of the lower limb. A gentle GA was given to keep the patient comfortable on the table for the prolonged surgery.

The procedure was done successfully without any complications and the pain score in recovery was 0/10. The infusion was continued as continuous with intermittent boluses to provide analgesia post operatively. The patient did not require any opioids during the stay and the catheter was removed after 5 days.

This case shows the importance of meticulous anaesthetic management perioperatively with comprehensive, multidisciplinary approach, integrating advanced regional anesthesia techniques, is crucial for ensuring patient safety and improving outcomes in such challenging scenarios.

The exact mechanism of action of local anesthetics in ESPB is not fully undersdut. A detailed study of the spread of local anesthetics during ESPB in published experiments on volunteers and deceased patients shows that a large part of the applied anesthetic or dye accumulates in the fascial space between the iliocostalis muscle and the serratus posterior superior muscle, i.e. outside the fascial space of the erectores trunci muscle group. We tried to apply a local anesthetic to the site of its accumulation in a direct way.

In a cadaver fixed by the F4L method, we applied 15 ml of blue water solution on the right side at the Th6 level and 12 ml of Latex green on the contralateral side into the space between the iliocostalis muscle and serratus posterior superior. We monitored the extent of distribution and the content of the depot under the fascia of the serratus posterior superior muscle. After obtaining the approval of the ethics committee, we performed the application of 20 ml of 1% xylocaine + 1 ml of Iomerone using the ESPB method and the SPPB method on one volunteer under US control. After application, we performed a CT + 3D reconstruction. We also determined the extent of analgesia using the pin prick method.

The extent of analgesia was identical between ESPB and SPPB. The distribution of contrast medium propagated more laterally in SPPB and craniocaudally to a lesser extent than in ESPB. Neither method demonstrated the spread of contrast to the paravertebral space.

The analgesic effect of ESPB is not due to the penetration of LA into the paravertebral space. Our results explain the analgesic effect of ESPB and offer a new technically simpler method of analgesia for postoperative conditions and for the treatment of chronic pain.

The erector spinae plane (ESP) block has been increasingly used as a regional analgesia technique to enhance postoperative pain control while reducing opioid consumption. This case report describes a 62-year-old woman undergoing elective on-pump coronary artery bypass grafting via median sternotomy, aiming to evaluate the effectiveness of ESP block as part of a multimodal analgesia strategy.

As part of a randomized, double-blind clinical trial, the patient received bilateral ESP block with either 0.2% ropivacaine or placebo, followed by patient-controlled analgesia (PCA). The block was performed under ultrasound guidance before surgery. Postoperative pain was assessed using the Numerical Rating Scale (NRS) for five days. PCA infusion volumes and bolus counts were also monitored.

Pain peaked on postoperative day 1 (10/10 during mobilization) and progressively declined. By day 2, the patient reported 0/10 pain scores at rest and during mobilization (Fig. 1). PCA demand increased until catheter removal on day 3 (Fig. 2). On day 5, a pain score of 7/10 during mobilization was reported, likely due to the discontinuation of PCA. The patient remained stable with no complications.

This case supports the potential role of ESP block in reducing postoperative pain and facilitating early recovery following cardiac surgery. Despite group allocation remaining blinded, clinical evolution suggests effective analgesia. Further studies are needed to confirm its role in fast-track protocols.

Hip disarticulation and hemipelvectomy are radical amputations associated with severe postoperative pain and significant morbidity. Due to concerns regarding coagulopathy and vascular injury, neuraxial techniques or lumbar plexus blocks may be contraindicated. The anterior quadratus lumborum block (QLB), an interfascial block targeting T7-L2 dermatomes, presents a potential alternative for safe, effective analgesia.

We present four cases of patients undergoing hip disarticulation or hemipelvectomy managed with continuous anterior QLB in conjunction with general anesthesia and regional anesthesia. All of the four patients received a bolus of 20 ml of 0.2 ropivacaine or 0.25% bupivacaine with epinephrine (1:400,000) at the plane between quadratus lumborum and psoas major. This is followed by continuous infusion of 0.125-0.2% bupivacaine or ropivacaine via patient-controlled analgesia (PCA) at 3-5 ml/h for 3-5 days. Supplementary pain medications include tramadol, gabapentin, and non-steroidal inflammatory drugs. Pain scores ranged from 0-3/10 at rest and 4-6/10 with movement. None of the patients required additional systemic opioids beyond low-dose tramadol or morphine. Phantom limb sensations were observed but were not associated with distress nor significant pain. No block-related complications were noted.

Cadaveric and clinical studies have demonstrated that anterior QLB may achieve spread to the lumbar plexus (L1— L3), involving femoral, lateral femoral cutaneous, iliohypogastric, and ilioinguinal nerves. Compared to neuraxial or lumbar plexus blocks, anterior QLB avoids deep vascular plexuses and carries a lower risk of hematoma, making it a safer option in patients at risk of bleeding. The QL block is unlikely to provide surgical anesthesia or complete regional analgesia for hip surgery as this would require lumbar and sacral plexus blockade.

Continuous anterior QLB may serve as a valuable alternative when neuraxial or deep plexus blocks are contraindicated among patients undergoing major proximal lower limb amputation. Its efficacy needs to be confirmed in adequately powered, well-designed, prospective randomized-controlled trials.

Hip surgery patients frequently experience moderate to severe pain following surgery, which makes it difficult for them to mobilize quickly, lengthens their hospital stay, and impairs their ability to function after the procedure. Opioids as the primary medication used to manage pain following surgery are linked to a number of unfavorable side effects.Iliopsoas plane block (IPB) is a recently developed motor-sparing regional technique targets the hip joint's sensory branches that originate from the femoral nerve and the accessory obturator nerve thereby increases the patient outcome in terms of early recovery, mobilisation and patient’s satisfaction. AIMS:To assess the analgesic efficacy of iliopsoas plane in patients undergoing total hip arthroplasty and primary objective is to see 24 hour morphine requirement.

We have described the use of iliopsoas plane block in eight patients who underwent Total Hip Replacement surgery under general anesthesia.Intravenous injections of Fentanyl (2 μg /kg), Propofol (2mg/kg), and Atracurium (0.5 mg/kg) was used to administer general anaesthesia (GA) followed by which endotracheal intubation was done. Ultrasound guided iliopsoas plane block was given with 10 ml of 0.5% of ropivacaine.. Each patient were received paracetamol 15mg/kg after induction and also used Post operatively 8th hourly, PCA pump was attached to every patient for 24 hr with a bolus dose of 1mg and lockout time of 10 min. 24hr morphine consumption was assessed postoperatively at 1hr, 6hr, 12hr and 24 hr postoperatively.

The mean (SD) opioid consumption came out to be 10.88 ±4.19 mg . No knee extension was possible in 7 patients in 1hr, 6hr, 12hr and 24 hr. Only 1 subject showed extension against gravity in 24hr assessment. No postoperative motor block was recorded.

Can be considered as alternative to PENG and SIFI Block. large RCT may be needed to confirm efficacy .

Mine-blast injuries from warfare in Ukraine present complex challenges in perioperative pain management. We report a case of a 39-year-old male who sustained a mine-blast injury to the left scapula and proximal humerus during combat operations, resulting in severe soft tissue damage and persistent pain during wound management and surgical interventions.

The patient underwent multiple surgical debridements and vacuum-assisted closure (VAC) therapy. Due to intense pain (NRS 7-8 points) unrelieved by systemic analgesics, a multimodal regional anesthesia approach was employed. Two tunneled catheters were placed: one for an erector spinae plane (ESP) block at the T5 level and another via the interscalene approach to the brachial plexus. Continuous infusion of 0.25% bupivacaine at 6 mL/hour was administered through each catheter. During surgical debridements, additional boluses of 50 mg bupivacaine were provided, along with midazolam sedation titrated to RASS -2 for optimal patient comfort and cooperation.

This combination of regional blocks provided effective analgesia, enabling tolerance of wound care procedures and reducing systemic opioid requirements. On postoperative day 7, both catheters were removed due to displacement. In the subsequent period, the patient required only intermittent single-shot nerve blocks for adequate pain control.

This case illustrates the feasibility and efficacy of combining prolonged ESP and interscalene catheter-based regional anesthesia for complex blast injuries involving the shoulder girdle. Such techniques offer significant analgesic benefits, minimize opioid use, and enhance patient outcomes in austere and military trauma care settings. Further research is needed to establish standardized protocols for prolonged regional analgesia in battlefield-related injuries.

Regional anaesthesia (RA) for cardiac surgery (CS) involving sternotomy remains underutilized, despite increasing evidence supporting its effectiveness for pain management. While various RA techniques are continually reviewed and refined, adoption in clinical practice varies. This study aimed to evaluate global anaesthetists' preferences for RA techniques and explore perceived barriers limiting RA use in CS.

An anonymized survey was distributed to 290 anaesthetists across 59 countries via mailing lists from anaesthesia societies including ESRA, ACTACC, and EBPOM. The survey assessed RA practices for sternotomy pain and factors influencing their use.

Among respondents, 41% specialized in cardiothoracic anaesthesia. Only 33% reported an ERAS program that includes CS at their institution; 19% had ERAS protocols excluding RA, and 48% had no ERAS protocol at all. Overall, 48% reported using RA for sternotomy cases, while 52% did not. Reported complications of RA in this context included haemodynamic instability (25%), haematoma (20%), local anaesthetic systemic toxicity (15%), arrhythmia (15%), block failure (5%), and pneumothorax (3%). Use of neuraxial techniques was rare: 7% used thoracic epidurals, 3% intrathecal opioids, and 90% did not use neuraxial approaches. The most commonly used RA techniques were: • Single-shot (SS) superficial parasternal block (24%) • SS deep parasternal/transversus thoracic muscle plane block (16.6%) • SS erector spinae plane (ESP) block (10%) • SS serratus plane block (9%) • SS PECS I/II block (8.7%) Other approaches included SS intercostal, rectus sheath blocks, and continuous catheter techniques (ESP, paravertebral, intercostal, serratus). Barriers to RA included time constraints (31%), patient anxiety/refusal (29%), and surgeon preference (18%). Other barriers included patient body habitus and limited drugs/equipment access.

This survey reveals global variability in RA practices for sternotomy highlighting key obstacles to broader implementation. Inconsistent ERAS integration, diverse technique preferences, and logistical/cultural barriers suggest opportunities for improvement through targeted education, protocol development, and institutional support.

Effective postoperative pain management is essential for recovery and patient satisfaction. However, discrepancies between prescribed and administered analgesics—often due to unclear instructions or insufficient education—can negatively impact outcomes. This study aimed to assess the frequency and consequences of such discrepancies.

A retrospective analysis was conducted on postoperative analgesic therapy in patients undergoing total knee arthroplasty in 2024 at the Clinic for Traumatology, University Hospital Center Sestre milosrdnice, Zagreb. Data were obtained from the Hospital Information System.

We analyzed data from 274 patients (156 women, 118 men; median age 70 years). Spinal anesthesia was used in 85% of cases. Perioperative analgesic blocks were given to 84.3% of patients—49.8% received a single-shot block and 50.2% a catheter. Catheters were mainly placed in the femoral region. Postoperative analgesia included parenteral ketoprofen, paracetamol, metamizole, oxycodone, and tramadol, as well as oral tramadol/paracetamol, short-acting morphine, and oxycodone/naloxone. In catheterized patients, local anesthetic boluses were possible up to three times daily. However, boluses were omitted in 41.4% of patients on day 0 and 25.9% on day 1. Only 15.4% received the full daily dose of paracetamol, and 59.4% received the full dose of ketoprofen, with some patients exceeding safe limits. Opioids were used perioperatively in 92.7% of cases.

Despite guideline recommendations for multimodal analgesia with limited opioid use, implementation was suboptimal. Improved adherence to protocols, clearer prescribing, and enhanced communication are needed to optimize postoperative pain management.

This study aims to develop a personalized prediction tool utilizing the decision tree algorithm to assess the risk of hypothermia in patients undergoing thoracoscopic radical lung cancer surgery in the post-anesthesia care unit (PACU), thereby providing a basis for precision postoperative management.

This retrospective study included patients from Chongqing Songshan Hospital who underwent thoracoscopic radical lung cancer surgery between 2020 and 2024, totaling 420 cases that met the inclusion criteria, excluding those with severe underlying diseases or missing intraoperative temperature control data. Data collected included demographic characteristics, preoperative evaluations (BMI, ASA classification, basal metabolic rate), intraoperative variables (surgery duration, fluid management, anesthesia depth changes, and temperature fluctuations), along with PACU temperature records. Hypothermia was defined as a core temperature below 36°C. A decision tree algorithm was employed to construct the predictive model, which was assessed using five-fold cross-validation and confusion matrices. Key performance metrics included AUC, accuracy, sensitivity, and specificity.

The incidence of hypothermia in the PACU was 21.7%. The decision tree model achieved an AUC of 0.90 (95% CI: 0.86-0.92), significantly higher than the logistic regression model (AUC = 0.82, P < 0.05). Key predictive factors identified were intraoperative temperature fluctuations, surgery duration, and basal metabolic rate, with the model showing a sensitivity of 84% and specificity of 88%. Targeted interventions based on the model effectively lowered the incidence of hypothermia in high-risk groups.

The decision tree-based predictive model developed in this study is accurate and reliable, effectively identifying high-risk patients for hypothermia in the PACU following thoracoscopic radical lung cancer surgery. This model serves as a scientific tool for postoperative risk assessment and can guide personalized temperature management, ultimately improving patient outcomes.

Video-assisted thoracoscopic surgery may be considered less invasive than an open thoracotomy, however it is also related with significant postoperative pain. Analgesia requirements after thoracic surgery are expected to be high and pain if remains untreated has been related with high incidence of chronic neuropathic pain. Therefore, a solid postoperative analgesic strategy should be implemented. Different regional analgesia techniques have gained popularity as we move away from thoracic epidural which used to be the gold standard for many decades for thoracic surgery. Intercostal blocks are a popular and well established and can be performed as one shot injection by anaesthesiologists. Nevertheless , they can also be performed by the surgical team under direct vision.

Our postoperative protocol for pain management after thoracic surgery includes polytropic analgesia with remifentanil TCI intraoperatively and also titrated doses of intravenous morphine 10 mg , paracetamol 1 gr, parecoxib 40 mg, clonidine 50-150 mcg, magnesium sulfate 25%. At the end of the procedure a single shot injection of 20 ml of ropivacaine 0,375% is given into the paravertebral space for postoperative analgesia. In addition paracetamol and parecoxib are prescribed regularly every 6 hours and every 12 hours respectively. Tramadol 100 mg can be given if needed as rescue dose for pain > 5 based on VAS score evaluation.

Based on our data, the vast majority of patients reports low pain with minimum requirements for extra analgesia for the first 24 hours. Patient satisfaction scores also achieve high levels. Postoperative complications, involving nausea and vomiting, pruritus and hypotension, are also extremely low.

Paravertebral blocks with Ropivacaine 0,375% performed by surgeons facilitate time efficiency and provide adequate postoperative analgesia for thoracoscopic video-assisted thoracic surgery.

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.

Nerve catheter infusions are increasingly more common for perioperative and post trauma analgesia. Catheters at our institution tend to be routinely removed on day 7, and receive daily pain team follow up during the working week. Nerve catheter related infections can lead to additional morbidity, pain and length of stay.

A retrospective review was performed of our local anaesthetic catheter database from April 2023 – August 2024. Patients who had been flagged as having nerve catheters sited received daily review by pain team (Monday to Friday) with complications logged. 23 reports logged of redness, and 6 of discharge from site. From these 29 events on closer review 12 cases were noted to reflect infection, 8 moderate and 4 mild.

974 infusion catheters followed up between April 2023 and August 2024. Infections noted in 12 catheters (1.23%), no documented/identified infections from paravertebral (302) , rectus sheath (117), wound infusion (5), intrapleural infusion (8), infraclavicular (10), supraclavicular (2). 10/12 tip results 8+ve tip results, 2 negative tip results, 2 not sent, no bacteraemia identified

Previous studies have suggested infection rate of 1.8 to 3%, with axillary and femoral sites most likely for infection. Theoretically tunnelling lines, and a single shot of antibiotics may minimise catheter infections. All catheters are likely to get colonised the longer they stay in. These are small numbers so it is difficult to identify patterns. 10/12 patients were already on antibiotics to cover soft tissue or chest infections. 7/12 catheters inserted in theatre complex, 2/12 inserted in ED, 2/12 inserted in ICU. 1 case insertion not documented, 1 case FAST not documented but likely to have been performed. No clear link with co-morbidities, although poor diabetic control has been linked to higher infection rates. Cases with infection will usually progress from mild-moderate-severe if catheter is left in situ.

Thoracic epidural analgesia (TEA) improves pain relief, and mental status, improves bowel function, and patient satisfaction and accelerates patient recovery in patients undergoing abdominal surgeries whenever compared with systemic opioids. The primary aim of this study was to observe the frequency of appropriate epidural catheter insertion site in adult patients scheduled for major abdominal surgeries and secondary aim were to observe the frequency of ineffective postoperative analgesia, side effects, complications of epidural infusion, and patient satisfaction.

This prospective study was conducted for a period of six months after approval from the Institutional Ethical Review Committee. All adult patients who underwent elective major abdominal surgery under general anaesthesia with an epidural catheter placed for postoperative pain management were included in this study. Post-operatively, all patients were managed by the acute pain management team. Data was collected in a specially designed proforma.

One hundred and four patients were included in this study. Sixty (57.69%) of patients were male. The epidural catheter was inserted congruent to the surgical incision that is at T10/T11 interspace or above in thirty-eight 38 (36.6%) patients, below T11 but till L1 in forty-five (43.3%) of patients, and below L1 in twenty-one (20.2%) patients. In the postoperative period, overall effective epidural analgesia was observed in seventy (67.3%) of patients. Regarding the side effects of epidural infusion, the motor block was observed in twenty-one (20.2%) of patients in the immediate postoperative period.

The frequency of appropriate epidural catheter insertion was found in 36.6% of patients. The frequency of ineffective postoperative analgesia was found in 32.7% of patients.

A 25-year-old male presented following a motor vehicle accident with multiple right-sided rib fractures, pulmonary contusion, a small pneumothorax, and thoracolumbar spine fractures (Figures 1, 2). Due to the extent of his injuries, emergency spinal fusion was indicated. On admission, he was hemodynamically stable but had hypoxemia (SpO2 95% on 50% Venturi mask, 91% on room air), tachypnea, dyspnea, and severe inspiratory pain.

To optimize analgesia and limit respiratory depression, an ultrasound-guided erector spinae plane (ESP) block was performed at the T8 level. General anesthesia included sevoflurane (1–1.2%) and fentanyl (250 µg). Surgery lasted two hours. Postoperatively, pain relief and oxygenation improved significantly (Figure 3).

Mild pain (VAS 2/10) recurred after 20 hours, and a continuous ESP block was initiated using ropivacaine 2% (6 ml/h), maintained for 60 hours. Upon completion, oxygen saturation on room air was 96%. The patient was discharged on postoperative day 5.

To our knowledge, this is the first case describing the use of an ESP block for thoracolumbar spinal fusion in a patient with rib fractures and hypoxemia. In such scenarios, the ESP block offers not only effective analgesia but also prevention of respiratory complications such as atelectasis, pneumonia, and worsening hypoxemia. It facilitates timely surgical intervention, reduces morbidity, and shortens hospitalization.

In late 2023, a metropolitan hospital transitioned from paper prescribing to an Electronic Medical Record (EMR). Since the introduction of EMR, if variable dose analgesia is to be prescribed, a singular, higher strength dose is to be charted, with the dose range specified in the comments However, as the comments are not readily visible (See attached images), we suspect that the higher dose is being administered on a more frequent basis. Aim: To evaluate the impact of EMR implementation on the administration of variable dose analgesia and the corresponding documentation of pain scores.

A retrospective data collection of patients who had been prescribed Oxycodone 5-10mg during day one to three postoperatively. The data collection included 51 patients from a pre-EMR cohort, and 50 patients from a post-EMR cohort. The data was then reviewed in respect as to whether the lower (5mg) or higher (10mg) dose was administered on each individual occasion, as well as the total oral morphine equivalent dosage (OMED) administered during the 3 day window. The data was also reviewed to determine if the patients pain score was documented within a one hour window of analgesia administration.

Our data showed that after EMR implementation, higher opioid doses were given more often (54% vs 41%, p=0.01475), although the resulting increase in OMED (15.45mg vs 12.75mg) was not significant (p=0.7818). Further, the absence of pain score documentation within 1 hour of administration significantly increased (88% vs 55%)

The findings were presented to the Analgesic Stewardship Committee and key stakeholders, highlighting that EMR based variable dose charting led to increased opioid use, raising concerns about potential overmedication. As a result, EMR workflow processes are being reviewed and educational material has been widely distributed. These initiatives aim to enhance patient safety, with a reaudit planned to assess effectiveness and compliance following implementation

Postoperative pain remains an undervalued aspect of surgical care in low-resource settings. However, adequate pain control has been associated with better functional recovery, shorter hospital stays, and higher patient satisfaction. In previous campaigns conducted by our team, regional anesthesia has been used as an analgesic tool in these contexts, although often performed using anatomical landmark techniques due to the lack of ultrasound devices—an approach that increases the risk of complications and results in variable analgesic efficacy.

In this context, we carried out a surgical campaign in April 2025 at the District Hospital of Kwimba, Tanzania, performing a total of 30 procedures: 29 abdominal wall surgeries (5 in pediatric patients) and one upper limb surgery. In all cases, peripheral nerve blocks were administered for postoperative pain control, this time guided by portable ultrasound. Given the absence of post-anesthesia care units and the limited availability of opioids, our aim was to provide effective, safe, and sustainable analgesia using local resources.

Results showed that 28 patients were discharged within the first 24 hours, presenting a VAS score < 5 with simple oral analgesia. Only two patients required extended observation due to surgical site hematoma, with no relevant clinical consequences.

This experience suggests that even in resource-limited settings, the use of ultrasound-guided nerve blocks significantly improves postoperative pain management, enabling early recovery, prompt mobilization, and reduced hospital stays. The introduction of accessible technology such as portable ultrasound devices can make a substantial difference in care quality, promoting safe, reproducible regional anesthesia with direct clinical impact.

Minimally invasive and robotic-assisted cardiac surgery has enabled faster recovery and fewer complications. However, the thoracic access used can cause significant postoperative pain, representing a challenge for anesthetic management. The erector spinae plane (ESP) block is a promising regional technique for thoracic analgesia. This case describes the use of a continuous ESP block via catheter for postoperative pain control in a patient undergoing robotic atrial septal defect (ASD) repair.

A 43-year-old female with multiple congenital ASDs and recent cerebellar ischemic stroke due to cardioembolic etiology was scheduled for urgent robotic repair. She was on rivaroxaban preoperatively. Total intravenous anesthesia was performed using propofol, remifentanil, and dexmedetomidine, after induction with sufentanil, etomidate, and rocuronium. A unilateral ESP block was performed at T5 under ultrasound guidance, with catheter placement for continuous analgesia. Cerebral oximetry (Hemosphere) was used during cardiopulmonary bypass. Postoperative analgesia was maintained with intermittent boluses of 0.2% ropivacaine for four days.

Surgery lasted 120 minutes without complications. The patient was extubated in the operating room and transferred to the ICU. Pain was well controlled with scores between 0 and 1, and no systemic opioids were required. A single bolus was administered on postoperative day two. The catheter was removed on day four, and the patient was discharged from the ICU on day three without adverse events.

Continuous ESP block proved to be a safe and efficient analgesic strategy in a patient undergoing robotic cardiac surgery. This technique allowed for excellent pain control, minimized opioid use, and promoted early recovery. The use of regional analgesia with continuous catheter infusion should be considered in enhanced recovery protocols for minimally invasive cardiac procedures.

The anterior approach of Quadratus Lumborum Block (QLB-A) is a promising alternative to thoracic epidural analgesia (EA). Despite being the gold standard, EA is associated with complications. This study aims to compare the efficacy of QLB-A and EA in pain management in open colorectal surgeries.

Totally, 10 patients undergoing laparotomic hemicolectomies with general anaesthesia were comparable (ASA II-III) and analysed when QLB-A was performed (6 patients) as a part of a multimodal analgesia or receiving EA (4patients). QLB-A patients in the lateral decubitus position received bilateral injections of 30 ml of 0.25% bupivacaine preoperatively with Paracetamol and Dexketoprofenum after surgery. EA patients were standardized at the Th9/10 level, with an initial of 7 ml 0.25% bupivacaine followed by a continuous infusion of 0.125% bupivacaine at 5 ml/h. As a primary outcome pain scores at rest and with activity were compared at 2, 6, 12 and 24 hours (h) postoperatively, secondary opioid consumption and time to the first opioid requirement.

Our preliminary data show that at 2 h, QLB-A demonstrated lower pain scores at rest (median 1.17 vs. 2.83, p<0.05) and with activity (median 2.00 vs. 4.83, p<0.05) compared to EA . At 6 h, QLB-A continued to show lower pain scores at rest (median 2.00 vs. 3.00, p=0.10) and with activity (median 3.33 vs. 4.33, p=0.10). By 12 h, pain scores were comparable, with both reporting a median pain score of 2.33, p=0.5 at rest and 4.00, p=0 with activity. Median opioid consumption was similar (QLB-A: 11.25 MME, EA: 10 MME, p>0.05). Time to the first opioid request was slightly longer in QLB-A group (median 6.5h vs 5h, p>0.05).

QLB-A demonstrates promising comparable analgesic efficacy to EA for laparotomic hemicolectomies, supporting its use as a viable alternative.

Fentanyl patient-controlled analgesia (PCA) has become the analgesic treatment of choice in the acute setting postoperatively in the Mercy University Hospital, Cork. This study will compare the pain profiles of patients who have underwent laparoscopic cholecystectomies (LC) and open cholecystectomies (OL) by examining trends of fentanyl PCA use. We will be aiming to recognise potential improvements in the delivery of pain medicine in the acute setting postoperatively.

This is a single centre, retrospective cohort study aiming to examine the use of fentanyl PCA since its introduction. The two groups of comparison in this study are those who underwent LCs and OCs. Quantities of fentanyl PCA used on day one postoperatively, it's use throughout stay and time to discharge will help to understand the need for fentanyl PCAs in the acute care setting.

Patients who underwent LCs were seen to use more fentanyl on average in the first 24 hours with 864mcg in comparison to 676.92mcg in OCs, possibly due to pneumoperitoneum. However, after the initial 24 hours postoperatively, the mean use of fentanyl in OCs and length of treatment far surpassed that of LCs, 2.58 days in comparison to 1.9 days respectively. 86.1% of patients received multimodal analgesia, with intravenous paracetamol (n=62) being administered to all of these patients. 83.3% of patients were well enough to undergo physiotherapy to improve postoperative recovery outcomes.

The use of fentanyl PCAs allowed adequate pain relief for a large portion of patients to mobilise early, undergo physiotherapy and thus improve recovery quality and shorten hospital stays. This study showed that changes to local prescribing protocols are required in both open and laparoscopic analgesics in order to optimise pain relief and improve recovery. Future research should consider comparing fentanyl PCAs to PCAs with other analgesics employed, with emphasis on multimodal analgesia.

Nerve catheter infusions for perioperative and post trauma analgesia are increasingly common. Catheter disconnection predominantly leads to removal of the catheter, which could lead to increased pain, and the need to resite. We reviewed our local anaesthetic nerve catheter infusion database to identify patients with catheter disconnections and catheter outcomes.

Retrospective review was performed of the pain service infusion catheter database from April 2023 to August 2024, identifying patients with witnessed or unwitnessed catheter disconnection. Electronic notes were reviewed to identify the location of disconnection, outcome of catheter, subsequent bacteraemia or catheter colonisation.

69 (7.1%) Catheters were blocked, dislodged, pulled out or disconnected. 21 unwitnessed disconnections, 1 witnessed disconnection. 22 catheter disconnections (2.25%) from a total 974 inserted followed up between April 2023-August 2024. 5 in critical care, 1 in recovery, 16 on wards. All catheters except a witnessed disconnection were removed. 2 were resited on same day, 2 resited following day, and 19 catheters not resited. 15/22 tips not sent, 3 no growth, 4 tip positive, no bacteraemia identified, (6/22) had blood cultures sent.

The disconnection rates are reassuringly low at our institution. The current default is removing any nerve catheter that is disconnected. This could lead to increased pain, and usage of emergency anaesthetic time and operative space. There is little evidence to guide practice, except for central neuraxial catheter practice. Majority of catheter disconnections are between catheter and filter. Theoretically bulk flow of pathogens down a catheter that is disconnected would be low. We propose to wrap catheter in sterile gauze, stop infusion and refer for pain team/on call anaesthetist review for consideration of disinfecting end of catheter, cutting back with sterile scissors and reattaching with new filter. One should still employ strategies to minimise disconnection in the first place.

Effective postoperative pain management is essential for promoting early mobilization and functional recovery following total knee arthroplasty (TKA), particularly within Enhanced Recovery After Surgery (ERAS) protocols. Continuous femoral nerve block (CFNB) and local infiltration analgesia (LIA) are two widely used techniques, though their impact on hospital stay may differ. This study compares the analgesic efficacy and length of hospitalization associated with CFNB and LIA in TKA patients.

A retrospective descriptive analysis was conducted involving 82 patients who underwent TKA with CFNB and subgluteal sciatic block in 2022, and 61 patients who received LIA between 2023 and 2024. All procedures were performed under spinal anesthesia. CFNB was maintained postoperatively with 0.2% ropivacaine at 4–6 mL/h. LIA was administered intraoperatively using 100–150 mL of 0.2% ropivacaine, dexamethasone, and adrenaline. Pain was assessed at 24 and 48 hours postoperatively, both at rest and during movement, using the Visual Numeric Scale (VNS). Median hospital stay was also recorded.

In the CFNB group, mean VNS scores at rest were 1.3 (24 h) and 2.1 (48 h), versus 4.86 and 4.1 in the LIA group. During movement, scores were 1.4 and 4.1 for CFNB, and 6.65 and 6.4 for LIA. Despite CFNB offering superior analgesia, the median hospital stay was longer (5.2 days) compared to the LIA group (3.2 days).

In conclusion, although CFNB provides better pain control, LIA is associated with a shorter hospital stay. These findings highlight LIA as an effective alternative for postoperative analgesia, supporting early mobilization and discharge within ERAS pathways.

Rib fractures following thoracic trauma are associated with significant morbidity and mortality, often exacerbated by inadequate analgesia impairing respiratory mechanics. Since 2018, Aberdeen Royal Infirmary’s rib fracture service has evolved to offer regional anaesthetic techniques to vulnerable patients.

This study reviews patients admitted with radiologically confirmed rib fractures between January and July 2024, focusing on the use of regional blocks, rib fracture scores, complication rates, and 30-day mortality.

Of the 100 patients included, the median age was 68 years, with 64% male. Rib fracture blocks were administered to 56 patients (56%), who had a higher average rib fracture score (11.63 ± 8.97) compared to those not receiving blocks (8.11 ± 6.04). Block types included 23 (41%) Erector Spinae Plane (ESP), 33 (58%) Serratus Anterior Plane (SAP), and 1 (1%) Parasternal Block. Complications were reported in 7 (21%) of SAP blocks versus 2 (9%) of ESP blocks, primarily due to mechanical or placement issues. The 30-day survival rate was slightly lower in the block group (88%) compared to the non-block group (93%), with the average age of deceased patients being 79.1 years.

Our data suggests blocks are appropriately targeted at patients with more severe injuries. This reflects global trends shifting from opioid-based to regional analgesia in rib fracture care. However, the higher mechanical complication rate associated with SAP blocks highlights an area for focused training and technique refinement, potentially improving patient outcomes and procedural success.

Hypospadias is one of the common congenital anomalies in males. Various modalities are used for pain management, including caudal, penile, pudendal, ring blocks, and systemic analgesics. There has yet to be a consensus regarding the most effective and safe analgesic method for controlling pain in these children. We planned this study to determine our institute's pain management practices for hypospadias surgeries.

After getting Ethics committee clearance, this retrospective cohort study reviewed 150 children with hypospadias undergoing surgery from January 2020 to December 2023. Data regarding the mode of pain management, postoperative opioid requirement, PACU discharge, and complications was collected from the records.

For postoperative pain, 33 (22%) children received caudal block, 60 (40%) penile block, and 57 (38%) were managed by intravenous analgesics. A significant difference was found in the 3 groups, with the IV analgesic group requiring significantly higher opioid boluses in PACU [43 (75.4%) required two boluses (p < 0.05)]. The difference in PACU discharge time among the three groups was statistically significant (p< 0.05), with IV analgesics groups having the highest (55 mins [47, 60]), the Caudal group at 35mins (30, 40), and the dorsal penile block group at 35mins (25, 40). There was no significant difference in complications like edema, meatal stenosis, urethra-cutaneous fistula, or wound dehiscence among all three groups.

Intravenous analgesics and regional blocks like caudal and penile blocks are the common pain management modalities in our institute. The regional blocks are effective in managing pain in the postoperative period and are not significantly associated with complications.

Combat injuries are one of the most common and widespread injuries in Ukraine and other countries at war. In many cases, they are characterized by extensive tissue and organ damage, accompanied by intense pain and a variety of stress reactions. The aim of the study was to determine the manifestations of pain syndrome in combat injuries in the early hospital period

Combat injuries are one of the most common and widespread injuries in Ukraine and other countries at war. In many cases, they are characterized by extensive tissue and organ damage, accompanied by intense pain and a variety of stress reactions. The aim of the study was to determine the manifestations of pain syndrome in combat injuries in the early hospital period

When assessing pain syndrome using the CPSCI scale, it was found that at the time of admission to the hospital, pain syndrome of mild and moderate intensity was observed in 47% and 47% of patients, respectively. Severe pain syndrome was observed in 6% of patients. Patients who were admitted to the hospital conscious characterized the pain as moderate (4-5 points) on the digital pain scale. At the time of admission to the hospital, the wounded with severe pain syndrome according to CPSCI showed moderate arterial hypertension (SBP - 110±1.2 mm Hg) and tachycardia (HR - 101±1.4 beats/min). Leukocytosis (14×109±0.09), an increase in the level of rod-shaped neutrophils

Thus, a significant part of the wounded who are admitted to the hospital on the first day after injury experience moderate pain. Pain syndrome and stress reaction to combat injuries manifest themselves in the form of hemodynamic changes and changes in the general blood test and glycemia. However, the issues of pain diagnosis and the development of analgesia methods require further study.

Background: Percutaneous nephrolithotomy and placement of nephrostomy tube is performed for renal stones > 2 cm in diameter. Attempts have been made to infiltrate local anaesthetics with or without adjuvants into the surgical site to reduce pain. We hypothesized that there would be a significant prolongation of the analgesic effect of local anaesthetic instillation along nephrostomy tube due to the adjuvant dexamethasone. Aims/Objectives: We compared the duration of analgesia in terms of the maximum numeric rating scale at 2,4,6,12,24, 48 and 60 hours postoperatively between Ropivacaine (R) and Ropivacaine-dexamethasone (R+D) groups. The total cumulative dose of Ropivacaine and Dexamethasone and the rescue analgesic fentanyl along with ESR and CRP were also determined.

After ethical approval and CTRI registration (CTRI/2020/03/024332), 64 ASA I&II adult patients were enrolled in this randomized double blinded prospective study divided into Group R – received 20 ml 0.2% Ropivacaine and Group R+D – received 20 ml 0.2% Ropivacaine with dexamethasone 8 mg, injected through a multi-lumen wound infiltration catheter.

The demographic profile of patients was similar in both the groups. The mean duration of analgesia was longer in Group R+D (21.3 +/- 2.1 hrs) vs Group R (10+/-1.9 hrs, p = 0.001). The mean NRS scores of Group R+D were significantly lower at all time intervals (p = 0.001). Also, the cumulative dose of ropivacaine and the total use of fentanyl postoperatively in group R was much higher (70+/-10.4 vs 56+/- 8.9 mcg, p = 0.02). The CRP levels were significantly lower in Group R+D (13.8 +/- 1.5 vs 23.1 +/- 1.2 mg/L, p=0.001 and 16.5 +/- 1.3 vs 28.5 +/- 1.7 mg/L, p=0.001, at 24 and 48 hours respectively).

We conclude that dexamethasone can be used as a suitable adjuvant to intermittent local anaesthetic infiltration after PCNL with nephrostomy tube for the prolongation of analgesia.

Enhanced recovery after surgery (ERAS) is an evidence-based protocol which is multimodal and multidisciplinary in nature and promotes faster recovery. Numerous studies have investigated the ERAS outcomes in orthopaedic joint surgeries and have concluded that they decrease length of hospital stay, decrease medical costs, decrease risk of post-operative complications and improve clinical outcomes. We decided to audit staff compliance in prescription of orthopaedic rapid recovery programme (RRP) drugs in the immediate recovery and post operative period following lower limb joint replacement surgery.

After gaining input from the acute pain team and audit supervisor an audit proforma was designed to gather relevant information. Data was collected over a period of 4 weeks by acute pain nurses on days 0 and 1 post-operatively. 44 patients were included in this audit and prescription of RRP drugs was audited against the local trust protocol.

Statistics revealed significant non-compliance in prescription of post operative RRP drugs especially the long-acting opioids(61%) and the Anti-neuropathic agents(43%) with respect to dose timing and the number of doses prescribed and required frequent acute pain team intervention to correct it. 23% patients had no NSAID prescription without appropriate reasoning. DOAC prescription was inappropriate in 23% patients and 14% had no thromboprophylaxis prescribed.

One of the main obstacles in success of ERAS remains reduced compliance and deviation from the protocol by the providers. For ERAS to be practised successfully, practical strategies based on sufficient understanding of the ERAS components and their outcomes are essential. Re-audit will be done in 6 months.

Vertebral Body Tethering(VBT) is an emerging surgical technique for the treatment of adolescent idiopathic scoliosis(AIS). Adequate perioperative analgesia is essential to facilitate early mobilization and minimize opioid consumption. Erector Spinae Plane Block(ESPB) is a novel regional anesthesia technique that has shown promising results in spine surgeries.

We report the case of a 12-year-old female with AIS who underwent VBT surgery with perioperative analgesia supported by bilateral ESPB. Following standard monitoring and induction of general anesthesia, the patient was positioned prone. Bilateral ESP blocks were performed at the L2 level under ultrasound guidance using the out-of-plane technique, with 10 mL of 0.25% bupivacaine administered on each side. The surgical technique involved the insertion of a single screw at T12, double screws at each level from L1 to L3, and a single screw at L4 to facilitate anterior VBT. The operation lasted approximately 2 hours, with stable intraoperative hemodynamics.

The postoperative course was uneventful and demonstrated effective analgesia. Pain was well controlled, with VAS scores of 2/10 at rest and 3/10 with movement during the first 24 hours. Opioid use was minimal; only a weak opioid (tramadol) was required as rescue analgesia, totaling a morphine equivalent dose of 3 mg. The patient ambulated on postoperative day one without significant pain.

Bilateral ESPB may serve as an effective component of multimodal analgesia for patients undergoing VBT for AIS, contributing to improved postoperative pain control and early mobilization. Further studies are warranted to validate its efficacy and safety in the pediatric population.

Neuropathic pain, affecting approximately 7–10% of the global population, is characterized by maladaptive pain sensitization mechanisms that often resist conventional monotherapies. To investigate the impact and efficacy evaluation of neurorehabilitation nursing combined with pharmacological sequential therapy on pain sensitization in patients with neuropathic pain.

A randomized controlled trial was conducted, enrolling 120 NP patients. Participants were randomly allocated to either the combined treatment group (neurorehabilitation nursing + pharmacological sequential therapy, n=60) or the control group (routine neurological nursing care + conventional pharmacotherapy, n=60). The neurorehabilitation nursing protocol included exercise therapy, sensory training, and psychological interventions. Pharmacological sequential therapy involved guideline-based stepwise medication adjustments (e.g., pregabalin, duloxetine combined with NSAIDs). Pain sensitization status was assessed using the Visual Analog Scale (VAS) and the Douleur Neuropathique 4 questionnaire (DN4) at baseline, 4 weeks, and 8 weeks post-treatment. Clinical efficacy was compared between groups.

At baseline, no significant differences were observed in VAS or DN4 scores between groups (P>0.05). At 4 and 8 weeks post-treatment, the combined treatment group exhibited significantly lower VAS scores (2.3±0.5 VS. 4.1±0.7; 1.2±0.3 VS. 3.5±0.6) and DN4 scores (4.2±1.2 VS. 6.8±1.4; 2.1±0.7 VS 5.7±1.1) compared to the control group (all P<0.05). The total effective rate in the combined treatment group was 95.0%, significantly higher than the 75.0% in the control group (P<0.05).

The integration of neurorehabilitation nursing and pharmacological sequential therapy significantly improves pain sensitization and enhances therapeutic outcomes in neuropathic pain patients, demonstrating clinical value for widespread application.

Anesthesia and surgery are associated with a weakening of the immune system and addition of anesthetic agents capable of ameliorating changes in immune function perioperative may have a positive effect on patients recovery.Ketamine can have positive effects on the postoperative immune response through a variety of mechanisms,but reports are conflicting.Aim:To investigate the impact of intraoperative subanesthetic doses of Ketamine on postoperative immune-inflammatory responses in laparoscopic anti-reflux surgery patients.Secondary outcome was postoperative pain intensity.

In this controlled study,64 adult patients (ASA I–III) scheduled for elective laparoscopic anti-reflux surgery were enrolled.Following induction and intubation, patients in the Ketamine group received a 0.4 mg/kg IV bolus, followed by a 0.25 mg/kg/h infusion continued till the scin was closed.The Control group received saline.Serum levels of CRP, IL-6, and NLR were measured preoperatively and at 24 and 48 hours postoperatively.Pain was assessed using a visual analog scale (VAS) at 1, 6, 12, 24, and 48 hours after surgery.

Differences of mean values of CRP, IL-6 and NLR between the two groups in the postoperative period were not significant. Serum IL-6 levels 24h i 48h after surgery increased lower in Ketamine group, as CRP serum levels at 48h after surgery, but without statistically significant differences( p=0.946,p=0.984 and p=0.907).However, VAS scores were significantly lower in the Ketamine group at all time points (p<0.001).

The addition of a low-dose of Ketamine in anti-reflux surgery patients did not exert any evident anti-inflammatory effect in terms of reducing the serum concentrations of inflammatory biomarkers,although leade in reduction of postoperative pain.

Quadratus lumborum (QL) blocks have become an important part of multimodality analgesia protocols in abdominal surgeries.This study aimed to compare the analgesic efficacy of QL type 1 (QLB1) block alone with the combination of QL types 1 and 2 (QLB1+2) in patients undergoing open gynecologic surgery under general anesthesia.

In this prospective, randomized study,72 patients undergoing elective open gynecologic surgery were divided into two groups:QLB1 (n=36) and QLB1+2 (n=36) block.All patients underwent general anesthesia.Postoperative evaluations;Visual analog scale (VAS) pain scores at 0,2,6,12 and 24 hours included total opioid consumption,number of patient-controlled analgesia requests, time to first non-steroidal anti-inflammatory drug (NSAID) use and patient satisfaction scores.

There was a difference in VAS scores at 0 (6.35±1.08 vs 7.17±1.09, p< 0.003) and 6 hours (3.91±1.07 vs 4.55±1.09, p< 0.022) postoperatively between the two block groups. There was no difference in VAS between the two block groups at other times. Between the two block groups, pca total consumption (204.4±114.72 mg vs 264±114.94 mg, p<0.04), pca demand (20.2±19.91174 vs 28.44±19.83246, P<0.013) and first NSAID application time were longer in the QLB1+2 group (p<0.016).Satisfaction was higher in the QLB 1+2 group (4.29±0.640387503 vs 3.94±0.635502193, p<0.005).

The combination of quadratus lumborum type 1 and 2 blocks provides more effective postoperative analgesia than type 1 block application alone.This method,which results in a decrease in pain scores, a decrease in opioid requirements,a delay in the need for rescue analgesics, and an increase in patient satisfaction,can be considered an effective analgesia strategy in open gynecological surgeries.

Posterior spinal fusion to correct adolescent idiopathic scoliosis is associated with severe postoperative pain, underscoring the need for effective multimodal analgesia. This study aims to evaluate the analgesic efficacy and safety of intrathecal morphine (ITM) combined with intravenous morphine patient-controlled analgesia (PCA).

A retrospective analysis was conducted on a population of 12 adolescents (14-18 years) who underwent posterior spinal fusion between January and May 2025. Patients received general anesthesia and a uniform multimodal analgesic regimen that included weight-based ITM (2–3 µg.kg⁻¹). Post-operatively, intravenous morphine PCA (1mg bolus, 10-min lockout) ran without basal infusion for 24 h, then continued at 0.3 mL.h⁻¹ until withdrawal on day 2. Pain intensity (NRS 0–10) at rest and on deep breathing or coughing, plus opioid-related adverse events - including pruritus, nausea/vomiting, sedation, respiratory depression, urinary retention and ileus - were assessed for 48h.

Amongst 12 patients, median resting NRS was 0.2 ± 0.6 at 6h, 1.9 ± 1.5 at 24h and 1.1 ± 1.0 at 48h and median coughing NRS was 0.8 ± 1.2, 3.4 ± 1.7 and 2.5 ± 1.4, respectively. Additionally, 72% of the population remained NRS ≤ 3 when coughing. Pruritus occurred in 25 % and nausea/vomiting in 33% throughout the 48h; no respiratory depression, urinary retention, ileus or clinically relevant sedation was reported.

ITM combined with a progressive IV morphine PCA as part of a multimodal analgesic regimen yielded low pain scores and mild side-effects after adolescent scoliosis correction, supporting its routine effective use and contributing evidence for subsequent dose-optimisation investigations.

Effective postoperative pain control without motor impairment is crucial for facilitating recovery in ambulatory knee surgery. While neuraxial and peripheral nerve blocks are commonly employed, their associated motor blockade may delay early ambulation. The adductor canal block (ACB) is well-established for providing predominantly sensory blockade. The biceps femoris short head (BiFeS) block, a more recent technique, has shown promise for sensory-selective analgesia in knee arthroplasty [1], but remains underexplored in knee arthroscopy. We present a case demonstrating the combined use of ACB and BiFeS block to provide effective postoperative analgesia while preserving motor function.

A 41-year-old male undergoing knee arthroscopy for meniscopathy received an ultrasound-guided ACB with 10 mL of 0.25% bupivacaine followed by a BiFeS block using 25 mL of 0.25% bupivacaine. General anesthesia was subsequently induced. No additional analgesics were administered.

In the post-anesthesia care unit, the patient reported a Visual Analog Scale (VAS) pain score of 2/10 and demonstrated a Bromage score of 0, indicating the absence of motor blockade. Ambulation was achieved within a few hours. Postoperatively, only intravenous paracetamol (1000 mg) was administered. The patient was discharged the same day without any complications. No rescue analgesia was required, and there were no readmissions within the first 24 hours.

This case demonstrates that the combination of ACB and BiFeS block—both primarily sensory techniques—can deliver effective postoperative analgesia without motor impairment, enabling early ambulation and same-day discharge after knee arthroscopy. Further studies with larger cohorts and randomized trials are warranted to confirm efficacy and reproducibility.References: 1.Kilicaslan A.PainMed.2025.doi:10.1093/pm/pnaf068

Vertebral Body Tethering (VBT) is an emerging surgical technique for treating adolescent idiopathic scoliosis (AIS). Adequate perioperative analgesia is critical for early recovery and reduced opioid consumption. The Erector Spinae Plane Block (ESPB) is a novel regional anesthesia technique that has shown promise in spinal surgeries.

Regional anesthesia is increasingly used in emergency surgeries to minimize the need for intraoperative and postoperative opioids, particularly in patients with poor general health. This can be achieved through techniques such as neuraxial anesthesia or peripheral nerve blocks.

Based on the results of our study Serratus intercostal interfascial plane block in supraumbilical surgery: a prospective randomized comparison (DOI: 10.23736/S0375-9393.20.14882-X), we have also decided to use the serratus intercostal plane block technique in patients undergoing emergency laparotomy, without applying local anesthetics to the surgical wound, and evaluate the outcomes.

The primary focus will be on comparing postoperative epidural analgesia with bilateral serratus intercostal block. Key outcomes will include pain intensity measured using the Visual Analog Scale (VAS) in the immediate postoperative period and at 24 hours, time to first ambulation, and the need for intravenous opioid rescue analgesia.

The lower intercostal nerves innervate the abdominal wall and peritoneum, including the rectus abdominis muscles and the skin of the anterior abdominal wall. The serratus intercostal plane block provides effective coverage for the laparotomy area without causing motor impairment in the lower limbs, a side effect commonly associated with epidural analgesia. Additionally, it avoids opioid-related adverse effects such as nausea, vomiting, delayed gastrointestinal and urinary function, and confusion, especially in elderly patients or those with a history of cognitive impairment.

Total knee arthroplasty (TKA) is a common major orthopaedic surgery associated with significant postoperative pain. PROcedure SPEcific Postoperative Pain ManagemenT (PROSPECT) Working Group recommend a single shot adductor canal block (ACB) combined with peri-articular local infiltration analgesia (LIA), and that intrathecal morphine be used only where both ACB and LIA are not possible. A recent audit in our institution showed suboptimal compliance with this, with 26.5% of patients receiving ACB and LIA, and 84% of overall patients receiving LIA. Educational interventions included anaesthesia departmental teaching and a mandatory regional course for anaesthesia trainees. Following this our primary aim was to assess the proportion of patients undergoing TKA who received both ACB and LIA. Secondary points included mode of anaesthesia, use of intra-thecal morphine, other peripheral nerve blocks and dose of dexamethasone.

We conducted a retrospective chart analysis of TKAs performed in March 2025. Of the 69 cases in this period, 5 records were unavailable and not included. Anonymised data collected looked at mode of anaesthesia and analgesia administered.

28 patients (43.8%) received both ACB and LIA. 89.1% received LIA. Overall, 61 patients (95.3%) received intrathecal morphine. Of those who received both ACB and LIA, 27 (96.4%) also received intrathecal morphine. Secondary results are shown in Figure 1.

Our re-audit has shown a 17.3% improvement in compliance with PROSPECT guidelines for the combined use of ACB and LIA for TKA, from 26.5% to 43.8%. It has also shown a modest improvement in the overall rate of LIA from 86.7% to 89.1%.

Enhanced Recovery After Cardiac Surgery (ERACS) is a novel, multimodal approach aimed at improving postoperative outcomes through optimized perioperative care. A core principle is minimizing opioid use to reduce associated side effects and facilitate faster recovery. The erector spinae plane (ESP) block, a simple regional anaesthesia technique, may support this goal by providing effective, opioid-sparing analgesia. This case series evaluates the efficacy and safety of bilateral ESP blocks in facilitating enhanced recovery in patients undergoing cardiac surgery via median sternotomy.

Ten adult patients scheduled for elective cardiac surgery received bilateral ultrasound-guided ESP catheters at T5–T6. Prior to induction, 20 mL of 1% Lidocaine and 20 mL of 0.25% Levobupivacaine were administered on each side. At surgery completion, 30 mL of 0.25% Levobupivacaine was given through each catheter, with repeat doses at 12 and 24 hours. All patients received regular paracetamol; opioids were reserved for rescue analgesia. Data collected included opioid consumption over 48 hours, pain scores (NRS), time to extubation, and block-related complications.

ESP blocks were successfully administered in all patients without complications. Opioid consumption was significantly reduced, with NRS scores consistently <3/10 at rest and on coughing. All patients were extubated within 6 hours postoperatively; three were extubated within 2 hours. No block-related adverse events occurred.

Bilateral ESP blocks offer safe, effective analgesia in cardiac surgery, supporting ERACS goals. Their use may reduce chronic sternal wound pain and should be evaluated further in larger studies.

To evaluate analgesic strategies used for thoracic surgery and assess their impact on patient satisfaction with post-operative pain control, benchmarked against the RCOA guideline of 90% satisfaction at 24 hours post-op.

A retrospective audit was conducted on 58 patients undergoing thoracic surgery. Data were collected on analgesic techniques used intra- and post-operatively, including use of regional blocks and patient-controlled analgesia (PCA), as well as pain scores recorded immediately and at 24 hours post-operatively.

Of the 58 patients audited, 26 underwent major thoracic procedures, 22 intermediate, and 10 were classified as other. The most common surgeries included lobectomy (n=22), wedge resection (n=5), bullectomy (n=6), thymectomy (n=3), and empyema washout (n=4). Overall, 72.4% of patients reported satisfaction with pain control at 24 hours post-operatively—substantially below the RCOA’s target of 90%. Fentanyl PCA was associated with higher satisfaction rates than morphine PCA. Regional anaesthesia, particularly single-shot blocks, correlated with reduced pain scores and improved satisfaction. Chronic pain patients were disproportionately represented among those dissatisfied with their pain control. Characteristics common to dissatisfied patients included: higher pain scores at 0, 6, and 24 hours; absence of regional anaesthesia; reliance on morphine PCA alone; lack of analgesic adjuncts such as ketamine or clonidine; and early need for rescue analgesia.

Current analgesic strategies fall short of RCOA targets. Fentanyl PCA and regional blocks improve satisfaction, especially in major thoracic procedures. Early identification of chronic pain patients and tailored, multimodal analgesia are essential.

Kidney transplantation (KT) recipients often experience moderate-to-severe postoperative pain, requiring multimodal analgesia to enhance recovery. This retrospective study assessed the efficacy of adjunct paracetamol and nefopam infusions in enhancing analgesic outcomes for living-donor KT recipients who received a transversus abdominis plane (TAP) block.

Consecutive living-donor KT recipients at our institute between January 2020 and March 2022 were divided into groups that received a TAP block with paracetamol and nefopam infusions (Group TA) or a TAP block without analgesics (Group T) during surgery. Among the study patients, 103 patients were included in each group. Postoperative pain intensity assessed using the visual analog scale (VAS), opioid consumption via patient-controlled analgesia (PCA) devices over 24 h, and postoperative outcomes were compared between both groups (Figure 1).

VAS pain intensity at rest was lower in group TA than in group T at 1 and 6 h after surgery [1 h: 29 (15–41) vs. 41 (29–51) mm, p < 0.001; 6 h: 32 (23–43) vs. 40 (32–54) mm, p < 0.001]. VAS pain intensity during coughing was lower in group TA [1 h: 46 (30–58) vs. 59 (48–69) mm, p < 0.001; 6 h: 51 (40–63) vs. 60 (45–71) mm, p < 0.001]. Also, PCA consumptions during the first 6 h and between 6–24 h post-surgery was significantly lower in group TA (Figure 2). Other postoperative outcomes did not differ between both groups.

Multimodal analgesia with intraoperative paracetamol and nefopam infusions improved postoperative pain control in living-donor KT recipients who received a preoperative TAP block.

To assess Static & dynamic pain using mean VAS score in in patients undergoing robotic- assisted and minimally invasive coronary artery bypass surgeries

Prospective observational study, 70 patients were enrolled in the study, using a computer-generated block randomization method. Adult patients (18 to 75 years) scheduled for Robotic-assisted and minimally invasive coronary artery bypass surgeries under general anaesthesia were included. 2 groups Group A - Intravenous PCA At the end of surgery but before the transfer of the patient to the ICU, Group B - patients received an ESP catheter at vertebra T5 under ultrasound guidance with IV fentanyl via patient-controlled analgesia device.

At 6 hours, Group A reported significantly higher mean VAS scores (2.81±0.65) compared to the Group B (2.45±0.72), which was significant. This significant reduction in static pain persisted at 12 hours and 24 hours . By 48 hours, both groups showed a reduction in pain with mean VAS scores and difference was statistically significant . Dynamic pain scores between both the groups at 6, 12, 24, and 48 hours were assessed postoperatively using the Visual Analogue Scale (VAS). At 6 hours, the Group A had significantly higher dynamic pain scores compared to the Group B . This trend of superior pain control in the Group B continued at 12 hours , at 24 hours and 48 hours with significance.

Study highlights the efficacy and safety of ESP block as an effective component of multimodal analgesia in patients undergoing robotic-assisted and minimally invasive direct coronary artery bypass surgeries.

Laparoscopic liver resection offers faster recovery and less postoperative pain compared to open surgery. However, anaesthetic management can be challenging due to haemodynamic instability. Spinal analgesia is preferable to epidural due to liver’s central role in coagulation. This case describes multimodal analgesia in a patient with opioid dependence undergoing laparoscopic hepatic bisegmentectomy.

A 62-year-old male with hepatitis C-related cirrhosis and heroin use disorder on methadone was scheduled for laparoscopic of liver segments II and III due to hepatocellular carcinoma. Combined anaesthesia was performed: single-shot subarachnoid block (150 mcg morphine + 4 mg ropivacaine 0.2%) was followed by total intravenous anaesthesia (TIVA) with propofol target-controlled infusion. Airway management was uneventful and neuromuscular blockade was achieved with rocuronium. Multimodal analgesia included intrathecal morphine/ropivacaine, paracetamol, metamizole, and wound infiltration with ropivacaine 0.75% (150 mg). Patient's anesthesia was managed with standard ASA monitoring, invasive blood pressure monitoring, and neuromuscular blockade monitoring using train-of-four ratio. The neuromuscular blockade was reversed with sugammadex.

The patient remained haemodynamically stable, extubation was uneventful and was then transferred to the post-anaesthesia care unit. Pain was managed with maximum dose of 0.25 mcg/kg/h ketamine infusion during six days. Discharge was on the seventh postoperative day.

This case illustrates the safety of combining TIVA, intrathecal analgesia, and peri-incisional infiltration for multimodal analgesia in laparoscopic hepatic bisegmentectomy, an innovative technique which also contributes to less post-operative pain. Regional techniques should be considered as a valuable component of enhanced recovery protocols, reducing the reliance on systemic opioids, particularly in opioid use disorder.

Laparoscopic cholecystectomy is commonly associated with moderate postoperative pain, which may impair early mobilization, prolong hospital stay, and reduce patient satisfaction. Effective multimodal analgesia is essential to enhance recovery and minimize opioid-related side effects. The modified thoracoabdominal nerve block via the perichondrial approach (M-TAPA) is a relatively new regional anesthesia technique targeting thoracoabdominal nerves to provide somatic analgesia of the anterior abdominal wall. The Quality of Recovery-15 (QoR-15) questionnaire is a validated patient-reported outcome measure that comprehensively evaluates postoperative well-being across physical and emotional domains. This study aimed to investigate the effect of M-TAPA on recovery quality following laparoscopic cholecystectomy using the QoR-15 scale.

This preliminary prospective study included eight patients undergoing elective laparoscopic cholecystectomy, randomly allocated into two groups: M-TAPA (n=4) and control (n=4). All patients received standardized perioperative care. QoR-15 scores were assessed at 24 hours postoperatively. Pain intensity was evaluated using the Numerical Rating Scale (NRS) at rest and during movement at six time points. Rescue analgesic consumption and adverse effects, including nausea, vomiting, and pruritus, were recorded.

The M-TAPA group had higher QoR-15 scores than controls (125.0 ± 9.1 vs. 100.5 ± 20.3, p = 0.069; Cohen’s d = 1.56). Movement-related pain was significantly lower at 12 and 24 hours (p = 0.039 and p = 0.020, respectively). No significant differences were found in rescue analgesia or adverse effects.

M-TAPA may improve postoperative analgesia and promote enhanced recovery as reflected in better patient-reported well-being on the QoR-15 scale.

Cluster headache is a rare primary headache characterized by strong, unilateral episodes from the vertex or occipital region, having peaks in the retro-orbital and/or temporal areas. Patients often describe the pain as sharp, burning, and stabbing, with an intensity reportedly 100 to 1000 times greater than that of a migraine.

A 45-year-old male with cluster headaches for 12 years was referred to the pain clinic by a neurologist due to deteriorating symptoms during the last 10 months. His medical regimen includes Verapamil (Isoptin), Valproate (Depakine) and Aspirin (salospir). His medical history was generally typical. On his initial visit, he reported substantial clinical deterioration, with up to four cluster episodes per day, each lasting 15 minutes to 3 hours. Due to the frequency and intensity of his episodes, he was overusing subcutaneous sumatriptan, consuming up to four doses daily. During the visit, an active cluster episode occurred, necessitating an urgent lesser occipital nerve block using 2 mL of 0.375% Ropivacaine and 2 mL of dexamethasone. The patient reported significant improvement, regarding his NRS pain level dropping from 10/10 to 4/10. This was followed by seven further peripheral nerve block interventions using the same protocol—initially every three days (four sessions), then every two weeks (the last three). During the intervals between blocks, the patient required sumatriptan on only three occasions.

At six-month follow-up, the patient became free of cluster episodes and utilized a modest medication regimen.

Peripheral nerve blocks of the head and neck serve as valuable diagnostic and therapeutic tools in headache management. They are effective both for acute pain relief and as a preventive measure in primary headache syndromes, particularly in drug-resistant cases. Interventional pain management techniques continue to expand the treatment options for these challenging clinical scenarios.

There is a lack of information regarding the demographics, clinical presentations, and pain procedures in chronic non-cancer pain (CNCP) patients attending pain clinics in the teaching hospital of LMIC. The study aimed to observe the demographic characteristics, clinical presentations, referral patterns, and frequency of pain intervention procedures, in CNCP patients presenting to the pain clinic at Aga Khan University Hospital, Karachi, Pakistan.

After approval from the Institutional ERC, all adult patients of both genders with CNCP presenting to the pain clinic were included in this retrospective descriptive cohort study. Data were obtained from patient’s medical records (from 2019 to 2023) on the initial and follow-up visits for three months and recorded in a data collection form.

A total of 675 patients were included in this study, of which 457 (67.7%) were female. Most patients (46.5%) were between 40 to 64 years of age and 62.1% had a BMI < 30 kg/m-2. 422 (62.5%) were referred to by family members or friends. Lower back and hip pain were the most prevalent site of pain in 371 (55%) of patients. 55.9% of patients presented with neuropathic pain, 31.7% with nociceptive pain, and 12.4% with mixed pain. Sleep was disturbed due to pain in 67.1% of patients and mood was disturbed in 61.5% of patients. Overall, 342 (50.66%) of patients needed at least one pain intervention procedure.

In this study, 55.9% of patients had neuropathic pain. Pain sites and clinical presentations were diversified, and pain management strategies were patient-centered and individualized.

Sluder’s syndrome is a rare form of sphenopalatine ganglion (SPG) neuralgia characterized by deep, unilateral facial pain, often accompanied by lacrimation and nasal congestion. SPG blocks typically offer only temporary relief. We report on the use of transnasal cryoneuromodulation as a minimally invasive method to achieve long-term pain control in a case of drug-resistant Sluder’s syndrome.

A 41-year-old woman with a 15-year history of continuous, pulsating, left-sided migraine (baseline NRS 3, crisis NRS 10) radiating from the fronto-orbital region and nasal ala to the zygomatic-maxillary and retroauricular areas was diagnosed with Sluder’s syndrome. A diagnostic SPG block with 2% lidocaine via the transnasal route led to complete relief (NRS 0), with symptom recurrence (NRS 4) after 15 days. After obtaining informed consent, the patient underwent fluoroscopy-guided transnasal cryoneuromodulation. A 21G cryoprobe (Cryo-S Painless®) was introduced via a silicone cannula along the superior border of the middle turbinate into the pterygopalatine fossa. Cryoablation was performed at −78°C for 4 minutes.

Fluoroscopy, assisted by contrast medium, enabled precise identification of the pterygopalatine fossa and confirmed accurate needle placement at the SPG level (Figg. 1-2-3). The patient experienced immediate and complete pain relief (NRS 0), maintained at 30, 60, 90, and 120 days. Mild, self-limiting epistaxis was the only adverse event.

Transnasal cryoneuromodulation of the SPG is a safe, effective, and reproducible method for prolonged pain relief. Compared to the infrazygomatic ultrasound-guided approach, the transnasal technique is simpler, less invasive, and better tolerated. Moreover, the supine position used in the transnasal approach is more comfortable for the patient than the lateral decubitus required for the infrazygomatic route, supporting its role in the management of SPG-related facial pain syndromes.

Lower extremity radiculopathy and edema are common presentations in elderly patients, often attributed to spinal or vascular pathologies. However, in immunocompromised individuals such as kidney transplant recipients, malignancy must also be considered. This case report highlights the importance of a broad differential diagnosis, particularly in long-term post-transplant patients with atypical symptoms.

A 77-year-old woman, 15 years post-kidney transplantation and under long-term immunosuppression, presented with left thigh numbness and lower extremity edema. Lumbar spine MRI initially suggested foraminal stenosis and herniation. Conservative management yielded limited improvement. As symptoms progressed, including persistent edema and right lower limb swelling, further imaging was performed.

Contrast-enhanced CT revealed a 9.9 × 6.4 cm retroperitoneal mass compressing the right iliac vessels. Biopsy confirmed diffuse large B-cell lymphoma (DLBCL), germinal center subtype, arising in a post-transplant immune-deficient setting. PET-CT staging identified multiple FDG-avid lymph nodes consistent with stage III disease. The patient underwent R-CHOP chemotherapy, with subsequent improvement in symptoms and reduction in tumor size. Immunosuppressive therapy was adjusted accordingly. She remains under oncologic follow-up with stable status.

This case underscores the importance of considering malignancy in the differential diagnosis of lower extremity symptoms in immunosuppressed post-transplant patients. Initial findings may mimic benign spine disorders, potentially delaying the correct diagnosis. Early, comprehensive evaluation is essential in such populations to improve outcomes.

Complex Regional Pain Syndrome (CRPS) is a challenging chronic pain condition with multifactorial causes, often arising after surgical trauma. Hyperbaric oxygen therapy (HBOT) has emerged as an adjunctive treatment designed to promote tissue oxygenation and reduce inflammation. This case report explores the use of HBOT in a patient with CRPS resistant to conventional therapy.

We report a case of a 44-year-old woman who developed CRPS within one year following surgery for the excision of Morton's neuroma, which was complicated by sesamoid necrosis. Despite treatment with corticosteroids, vitamin C, and acetylcysteine, her symptoms persisted. She subsequently underwent 80 HBOT sessions.

The patient experienced transient improvement in pain intensity and functional capacity during the treatment period. HBOT is believed to exert its effects by increasing oxygen delivery to ischemic tissues, modulating inflammatory responses, and facilitating cellular repair. In this patient, the temporary relief observed suggests that while HBOT can yield short-term benefits, its effects may not be sustained once sessions are discontinued. This outcome signals the need for further investigation into optimal session protocols and potential combination therapies to achieve lasting symptom control in CRPS.

This case highlights that HBOT may offer a viable option for transient symptom relief in CRPS unresponsive to standard treatments. However, its long-term efficacy remains inconclusive. Further controlled studies are essential to establish the role of HBOT within a comprehensive, multimodal treatment strategy for patients with CRPS.

Xiphodynia is a rare and often misdiagnosed musculoskeletal condition that presents with anterior chest pain, frequently mistaken for cardiac or gastrointestinal disorders. This case aims to highlight the diagnostic challenge of xiphodynia and evaluate the efficacy of bipolar pulsed radiofrequency (pRF) as a treatment option in refractory cases.

We present a 32-year-old male with chronic sternal pain following a motorcycle accident. Conservative treatments, including oral analgesics, lidocaine patches, and corticosteroid injections, provided only transient relief. Clinical examination revealed localized tenderness over the xiphoid process. Bipolar pRF was performed under ultrasound guidance, with transversely positioned needles and six minutes of stimulation.

At one month post-procedure, the patient reported substantial pain relief, reduced breakthrough pain, and pain-free intervals. No rescue medication was required. At six months, a slight increase in pain was noted, mainly at night and during periods of stress, which responded well to oral analgesics. Numeric Rating Scale (NRS) scores decreased from an average of 8/10 pre-procedure to 3/10 at one month and 5/10 at six months.

This case underscores the importance of including xiphodynia in the differential diagnosis of anterior chest pain, especially after trauma. Clinical recognition through palpation and exclusion of other causes is essential. Bipolar pRF may be a safe and effective therapeutic option for patients unresponsive to conservative management, offering sustained symptom relief and improved quality of life.

Ketamine, a well-established anaesthetic agent, has been used in clinical practice for about 50 years. It produces a distinct state of "dissociative anaesthesia" wherein patients appear awake but remain unresponsive to surgical stimuli. Beyond its anaesthetic properties, ketamine has recently emerged as a valuable treatment option for neuropathic pain, particularly in patients unresponsive to conventional treatments. Its ability to block NMDA receptors in the central nervous system is possible mechanism of action in neuropathic pain relief1. In this case series we presents the clinical outcomes of three patients who received ketamine infusions for chronic pain management.

1st patient : A 51-year-old woman presented with right forearm and hand pain for the last 4-months. Pain was moderate in intensity, burning, stabbing, & shooting and unresponsive to opioids and physical therapy. She achieved significant pain reduction and improved mobility after a series of ketamine infusions. 2nd Patient : A 24-year-old girl with chronic pelvic pain for 2 years, unresponsive to conventional pain therapy and multiple surgeries. She showed slight improvement in pain intensity and functional capacity after ketamine infusion. 3rd Patient : A 38-year-old man with a history of two previous lumbar spine surgeries, presented with severe lower back and limb pain, along with symptoms of burning and current-like sensations in his limbs. He experienced substantial pain relief and enhanced quality of life following low-dose ketamine infusions.

All patients tolerated the infusions well, with transient dizziness being the most common side effect. there was a significant pain relief .No serious adverse events were observed.

This case series highlights the potential efficacy and safety of ketamine infusions in managing diverse chronic pain conditions. While results are promising, further studies are needed to establish standardized protocols and long-term outcomes.

Gluteal tendinopathy is a common condition causing lateral hip pain. It is also a common comorbid cause of chronic pain. Hydro dissection, a minimally invasive technique involving injection of fluid to separate fascial layers and release entrapped nerves and tendons, has emerged as a potential treatment. Its use in Gluteal Tendinopathy has not been reported.

We present the case of a 67-year-old female with refractory left gluteal teninopathy confirmed on MRI imaging. Despite extensive conservative therapies, including medications and physical therapy, she continued to experience left lateral hip pain.The patient underwent ultrasound-guided gluteal tendon hydrodissection as a targeted approach to address perineural inflammation and nerve entrapment. Hydrodissection of the gluteus maximus and gluteal medius tendons was performed on the left side. A low concentration (5%) dextrose solution was used to free the tendons from surrounding scar tissue and muscle adhesions. The procedure was performed in a theatre setting.

Following the hydro dissection procedure, the patient experienced improvement in lateral hip pain, with sustained improvement over two months, at follow-up. Functional outcomes, including range of motion and daily activities, improved substantially. No complications were reported.

This case supports the potential role of dextrose hydro dissection as a safe, minimally invasive treatment option for gluteal tendinopathy. Hydro dissection offers an alternative to more invasive interventions and warrants further investigation in the management of Gluteal tendinopathy.

Transforaminal epidural steroid injections (TFESI) are commonly preferred interventional treatments for low back pain due to lumbar radiculopathy. Complications related to the procedure may take place. We report the case of a patient with a combination of intradural contrast media spread and dural pulsation during TFESI for lumbar radicular pain and aim to raise awareness of the importance of recognising and interpreting atypical images in interventional pain procedures for patient health.

A 67-year-old woman presented with low back and right leg pain due to spinal stenosis. We performed right L3 TFESI with a 22G 90 mm Quincke spinal needle to the area compatible with the right L3 neural foramen under the guidance of a C-arm fluoroscopy (GEMSS-Spinel 3G) device. On imaging, the needle placement was consistent with the epidural region, but the contrast spread suggested subdural spread. When we administered contrast material again (1 cc), we observed that the contrast extended and widened a little more in the cranio-caudal direction in the same region but did not disperse. Therefore, we obtained a live fluoroscopic image. The contrast media was accumulated in the same region and showed pulsatile properties in the images. We speculated that this image might be a combination of intradural spread and dural pulsation.

We terminated the procedure since the image was atypical. The patient did not develop any neurological deficit, we obtained lumbar MRI and CT angiography to exclude other causes. The neuroradiologist at our hospital evaluated the examinations and reported no evidence of venous dilatation, arteriovenous fistula or arteriovenous malformation in the spinal region. To alleviate the persistent pain of the patient, we prescribed medical treatment.

Atypical contrast media distributions may be seen during procedures. To avoid possible complications, it is vital for physicians to have a thorough knowledge of the contrast media distribution pattern.

BEYOND PAIN – A RAY OF HOPE Introduction: Chronic pain affects 1 in 5 globally, impacting physically & emotionally. With Multimodal therapy, psychological support, and resilience, recovery is possible. Pain Mechanism: Central sensitization, causes brain to perceive pain without injury. Neuroplasticity sustains pain, but also enabling recovery through therapeutic rewiring. Clinical Insight: Biopsychological care, and mindset shift impact recovery. HOLD ON: FIGHTING DEPRESSION IN CHRONIC PAIN Introduction: Depression and chronic pain often coexist, worsening each other and reducing functional outcomes & quality of life. Neurobiology: Shared neurocircuitry & neurotransmitter dysregulation amplifies pain through negative emotions & inactivity.. Clinical Insight: Integrated treatment with antidepressants, CBT, and mindfulness ease both pain and mood

SCORCHED: THE BURNING AGONY OF TRIGEMINAL NEURALGIA Introduction: Trigeminal neuralgia causes brief but excruciating facial pain, described as electric shocks significantly impacting daily activities. Pain Mechanism: Vascular compression leading to demyelination and hyperexcitability. Causing sharp pain along V1, V2, and V3 branches. Clinical Insight: Carbamazepine is first-line. Severe cases may need decompression, ablation, gamma knife surgery

Medium: Caran D’Ache Luminance White colour pencil and Faber castell polychromos 60 colour pencils on A4 size Strathmore vellum artgain 400 series coal black sheets Artistic reflection: Image captures the duality of living with chronic pain. A woman shrouded and with thorns below– symbolizes entrapment & emotional burden. Yet above, she re-emerges – wings open, in sunlight and butterflies—symbolizing resilience & renewal Pain Science Correlation: The dark, thorny half represents central sensitization, persistent pain from a sensitized nervous system. The bright transformation reflects neuroplastic healing, wherein therapy help rewire the brain. Butterflies mark new, adaptive neural pathways

Art is the bridge to the unseen struggles of chronic pain with the science behind it. Through my poster I want to present not just their suffering—but the strength, transformation, and hope that emerge beyond it.

Sciatic endometriosis is an infrequent extra-pelvic manifestation of endometriosis that can mimic radiculopathy, leading to diagnostic delay and unnecessary treatments. We present a case highlighting the clinical clues and diagnostic pathway to raise awareness among pain specialists.

A 43-year-old woman was referred to our pain clinic with a 3-year history of insidious, radicular-type pain radiating from the left buttock to the foot (VAS 9/10), accompanied by paraesthesias and cyclical worsening during menstruation. Suspected piriformis syndrome and disc herniation led to unsuccessful physiotherapy and a non-relieving diagnostic injection. Examination revealed antalgic gait, left foot dorsiflexion weakness (3/5), positive straight-leg-raise, and piriformis tenderness. Lumbar MRI and EMG did not reveal any abnormalities. With no lumbar pathology to explain the radicular symptoms, pelvic and lumbosacral plexus MRI were performed, revealing endometriotic lesions compressing the sciatic nerve. Diagnosis was confirmed through consultation with gynaecology.

Pharmacological treatment with gabapentin and paracetamol-codeine reduced pain to VAS 7/10. Fluoroscopy-guided pulsed radiofrequency of the dorsal root ganglia at L4, L5, and S1, the roots that converge to form the sciatic nerve, further decreased pain to VAS 2/10. Laparoscopic excision was performed 8 weeks later. At three-month follow-up, the patient was pain-free with normal gait and dorsiflexion.

Cyclical sciatic or gluteal pain unresponsive to conventional lumbar or piriformis interventions should prompt consideration of sciatic endometriosis. Detailed menstrual history, targeted pelvic/plexus imaging, and early multidisciplinary referral are crucial for timely diagnosis. Awareness of this entity can prevent prolonged patient suffering and guide effective combinational pain and surgical therapies.

Shoulder pain is the second most common joint complaint and often arises from a combination of cervical and shoulder joint pathologies. This case series evaluates the efficacy of peripheral nerve stimulation (PNS) targeting the upper trunk of the brachial plexus in managing shoulder and cervical radicular pain.

Four patients with varying shoulder pathologies underwent the temporary SPR PNS System for 60 days, with clinical outcomes assessed pre- and post-intervention using validated tools, including the Numeric Rating Scale (NRS) for pain, Patient Global Impression of Change (PGIC), PROMIS Neuropathic Pain Quality 5a, Sleep Disturbance Short Form 6a, Physical Function Short Form 6b, and a PNS-specific questionnaire.

Across all cases, patients demonstrated substantial improvements in pain reduction, sleep quality, physical function, and overall quality of life. Notably, enhancements included increased range of motion and better performance of daily activities, with some patients reporting reduced reliance on opioid medications.

These findings suggest that PNS of the upper trunk of the brachial plexus may be an effective, minimally invasive treatment option for improving quality of life in patients with complex shoulder and cervical radicular pain syndromes.

Peripheral nerve stimulation (PNS) of the occipital nerve at C2 is a novel approach that can be utilized in occipital pain treatment.

In this retrospective case series, we retrospectively reviewed patients who received percutaneous implantation of neurostimulator electrodes with the SPRINT PNS System (SPR Therapeutics, Cleveland, OH, USA) from August 2022 to December 2023 at MetroHealth Medical Center Pain Clinic for occipital pain, occipital headaches, and cervicogenic headaches. They were treated with temporary percutaneous implantation of neurostimulator electrodes targeting the greater occipital nerve.

There were overall decreases in opioid consumption and pain scores. The quality of life and sleep, assessed by PGIC and PROMIS scales, have increased with high patient satisfaction.

This case series demonstrates the potential for the temporary PNS at C2 for greater occipital nerve stimulation as a therapeutic option for refractory occipital pain.

Notalgia paresthetica (NP) is a neuropathic syndrome that involves the unilateral infrascapular region, typically corresponding to the T2–T6 dermatomes. It is classically characterized by localized, episodic pruritus, burning, tingling, and pain, often accompanied by secondary skin lesions resulting from chronic scratching. Although the pathogenesis has not been fully elucidated, it is believed to be the result of spinal nerve impingement or nerve trauma. We aim to present an example of a successful management and highlight the importance of a multidisciplinary approach to it.

A 65-year-old female patient, with a medical history of hypothyroidism, nodular thyroid disease and hypertension, started to feel a burning sensation in the left medial infrascapular area by the end of 2022. After dermatology and physical medicine and rehabilitation consultation, a diagnose of NP was done. The initial treatment involved five sessions of cervico-dorsal mesotherapy and application of 5% lidocaine patch, with limited pain control. By the end of 2023 the patient was also receiving physiotherapy twice a week. With no significative improvement, the patient was referred to the chronic pain consult. Since then, was submitted to left dorsal paravertebral block, four capsaicin applications and started 30 mg duloxetine and 50 mg pregabalin twice a day. She was also submitted to four applications of 10 mL subcutaneous ozone.

Since the referral to chronic pain team and with the implemented multimodal approach, the patient had a significant clinical improvement, with less pain and fewer itching episodes in the first month.

NP is a clinically poorly recognized syndrome. The lack of studies makes it difficult to optimize the recommendations to treatment. To date, there has been no effective treatment for this condition, decreasing the patients quality of life. This report illustrates a case of treatment success and emphasizes the need for a multidisciplinary and multimodal approach.

Intercostal neuralgia causes sharp, burning pain along the intercostal nerve distribution and can be refractory to conservative treatments. Standard management includes physical therapy, nerve blocks, and thermal ablation, but durable relief is often elusive. Dorsal root ganglion stimulation (DRGS) offers targeted neuromodulation but carries risks such as lead migration and infection, and thoracic applications remain off-label. Peripheral nerve stimulation (PNS) placed near the target nerve has emerged as a less invasive alternative, yet its use in bilateral thoracic intercostal neuralgia has not been reported.

We describe a 71-year-old woman with chronic, refractory intercostal neuralgia following multiple spine surgeries. After transient relief from thoracic paravertebral blocks, she underwent a 60-day trial of ultrasound- and fluoroscopy-guided PNS using the SPRINT MicroLead system. Percutaneous leads were positioned 1 cm superficial to the T7 dorsal root ganglia bilaterally, confirmed by patient feedback and imaging. Pain scores, medication use, and functional status were recorded throughout the trial and up to 18-month follow-up.

During the trial, the patient reported 90% pain reduction on the left and 70% on the right, allowing cessation of gabapentin and improved sleep. No adverse events occurred, and lead integrity was confirmed at removal. At 18 months, she remained pain-free in the thoracic distribution, with only residual lower back discomfort unrelated to the trial. Her quality of life and daily activities showed marked improvement.

This first reported case of bilateral thoracic PNS targeting the T7 dorsal root ganglia demonstrates that percutaneous PNS can provide safe, effective, and durable relief for refractory intercostal neuralgia. These findings support further investigation of PNS as a minimally invasive neuromodulation strategy in this challenging patient population.

Advances in cancer survival rates have shifted pain management strategies from short-term to long-term approaches, emphasizing chronic pain control. Intrathecal (IT) therapy delivers sustained analgesia, minimizes systemic side effects, and can significantly improve the quality of life in patients with refractory cancer pain and has been widely used.

A 71-year-old woman with metastatic ocular malignant melanoma and urothelial carcinoma presented with severe refractory nociceptive and neuropathic pain (VAS 8) caused by osteolytic metastases in her spine, radiating to her abdomen and lower extremities, and resistant to multimodal approach using high-dose opioids and non-opioid analgesics, neuropathic pain medications, and adjuvants, administered through various routes. The pump was surgically implanted and a catheter was inserted to level Th 9, initially delivering 1 mg/day morphine and 6 mg/day bupivacaine intrathecally. Within three days, her pain improved to VAS 3, with enhanced quality of life as measured by validated questionnaires. Dose adjustments were made based on disease progression: after three months, clonidine (65 mcg/day) was added, with increased doses of morphine (2.6 mg/day) and bupivacaine (19.5 mg/day). Pain control stabilized at VAS 3 without significant side effects, and symptoms like constipation and dizziness diminished. The patient passed away peacefully six months post-intervention.

Intrathecal drug delivery directly into the cerebrospinal fluid bypasses the blood-brain barrier, enabling lower drug doses than systemic routes while maintaining effective analgesia. Using implantable IT pumps represents an advantage compared to traditional intrathecal therapy methods, exhibiting a long-term efficacy for refractory cancer pain treatment, reduced infection risks, reduced caregiver burden, enhanced safety, and improved patient quality of life.

Intrathecal therapy using an implantable pump provided effective pain relief and improved quality of life for a patient with refractory cancer pain. This first case in Slovenia marks a significant step toward integrating IT therapy using implantable pumps into standard palliative care.

patient found to have had many injections for chronic back pain. Given various injections based on lumbar facet joint artro-pathy and disc degeneration. unsatisfactory outcome.

Patients selected based on their history and number of injections given for pain. The injections were done under fluoroscopy and Omnipaque used to highlight the congenital transverse process and Iliac Crest pseudojoint. Injection of a mixture of 1% Lidocaine 3ml. with 40mg. Depo-Medrone was done. Immediate pain relief experienced by patient.

Patients were followed up , face to face and examined. All patients were found to be pain free after 6 months.

This is relatively a commonly missed diagnosis and hence goes untreated. A careful examination and the images done will help to diagnose the Syndrome.

Low back pain (LBP) means chronic pain which is the most common diagnosis in pain therapy.In 90% of cases of non-specific etiology and with serious pathology in the background only about 1%.

A 53-year-old man presents to the pain therapy outpatient clinic due to chronic progressive LBP for the past 6 months refractory to conservative therapy and procedures.MSCT LS of the spine attached, reduced space of L4-L5 intervertebral discs and biconcave reduction of L5 vertebral body height.Without accompanying comorbidities,well-controlled hypertension,smoker.The nature of LBP directed us to epidurolysis as a modality of pain therapy,an L4/L5 epidural block was initially performed (Chirocaine 0,20% 10ml with adjuvants).The pain in the spine, hips and down the legs subsided.After four days the patient comes for a check-up and states that the LBP is resolved but that he feels pressure above the pubic bone,heaviness and the need to urinate frequently.EHO of the abdomen was performed,AA dilatation was observed and MSCT was indicated AA infrarenal maximum width up to 63-57mm with expansion into the right iliac artery which is aneurysmally altered 48-33mm in length of 45mm.AA wall with old dissection partially calcified thrombosed with acute dissection and intraluminal hematoma.Emergency vascular surgery was performed,an open repair of the infrarenal segment AA with a bifurcation graft on the iliac arteries was performed.Perioperative course without complications, one month after the operation, the vascular status was normal and there was no LBP.

Pain therapy as a therapeutic procedure is sometimes also a differential diagnosis because of that it is crucial to recognize the clinical manifestations of LBP and take comprehensive history to rule out another pathologies under LBP.

The present case highlighted that those common presentations such as LBP can be indicative of serious underlying pathology where timely diagnosis improves prognosis and survival.Pain therapy must be safe and secure.

Adolescent complex regional pain syndrome (CRPS) is rare and there have not been conclusive treatments.

Case report: An 18-aged female patient had visited our pain clinic with left arm pain. In past history, ulnar nerve decompression surgery had been operated on her left elbow twice in orthopaedic clinic. After surgery, she had great pain, swelling, tremor, color changes in her left arm and hand. In physical examination, pain was over 7/10 in visual analogue scale. Allodynia and hyperalgesia existed in left hand and arm. Hot sensation was in left hand. Sweating had increased in left hand and arm. Tremor was in left hand. In three phase bone scan, blood pool and bone uptake in left hand. In bone densitometry, lumbar spine and trochanter were normal, but in upper arm, right arm was 0.806 g/cm2, left arm was 0.642 g/cm2. In magnetic resonance image of left hand, there were diffuse signal change in muscle of left hand combined with subcutaneous edema. In thermography, there were temperature differences in left hand of maximum 1.2 degrees. There were no abnormal findings in left arm x-rays. After admission, epidural catheter was inserted in left upper thoracic segment but left arm pain was not improved. The patient had left arm allodynia, hyperalgesia, severe pain, muscle weaknesses, and tremor, but there was no dramatic pain subside and functional improvements. We had planned for passive physical exercises under sedation and brachial plexus block.

One month after last treatment, patient visited our outpatient clinic. There was much improvement in allodynia, hyperalgesia, and pain. And range of motion in wrist, elbow, were much improved.

Severe allodynia, hyperalgesia have been great problems in rehabilitation of CRPS patients. Sedation and regional nerve block would be good treatment option in CRPS patients.

Post-traumatic chronic pain (PTCP) is defined as persisting pain beyond the healing process after injury. Multiple drug intolerance syndrome (MDIS) is an under-reported condition that may restrict treatment of several diseases. We present a case of PTCP complicated by multiple drug allergies and intolerances.

A 53-year-old woman was referred to our Pain Medicine Unit in 2019 due to refractory right cervicobrachialgy and cervicogenic headache, initiated after traumatic brain injury with cervical trauma in 2015. She mentioned adverse effects to multiple drugs, including anaphylaxis. After referral to Immunoallergology, allergies to morphine, lidocaine and methylprednisolone were confirmed. She also developed intolerance to drugs from different pharmacological classes: antidepressants, gabapentinoids and opioids. She was referred to Genetic Medicine, with pharmacogenomic study revealing no significant findings to modify pain therapy. Genetic testing excluded monogenic allergic diseases, but detected the RYR1 gene pathogenic variant associated with malignant hyperthermia susceptibility. Her treatment included non-pharmacologic strategies as physical therapy and acupuncture, with incomplete pain relief. Invasive procedures were also performed: ultrasound guided right suprascapular nerve block; posterior serratus, teres major and occipital fascial plane injections; greater occipital nerve block; cervical trigger point injections. She had functional improvement afterwards, however myofascial syndrome persists with quality of life impairment and need for a multidisciplinary approach. Additional invasive procedures are being planned to achieve longer lasting effect.

PTCP treatment is complex, especially when patients present adverse effects to several pharmacological classes. Multidisciplinary approaches should be used in these cases. Immunoallergology added valuable information, confirming safety of the drugs in use. Genetic testing is useful in MDIS cases with refractory chronic pain. Although in this case no gene related allergic diseases were identified, the RYR1 pathogenic variant was a relevant finding. Invasive procedures' aim is a longer lasting pain relief with a lower need for medications that patients may not tolerate.

Nutcracker syndrome is a rare vascular condition, leading to chronic abdominal and pelvic pain due to venous congestion often refractory to conventional treatments. The presence of Factor V Leiden mutation, a genetic disorder that increases the risk of venous thrombosis, complicates clinical management by elevating thrombotic risk. Chronic pelvic pain is a challenging clinical problem with multifactorial etiology, often underdiagnosed, can have mechanical, inflammatory or neuropathic origin. The superior hypogastric plexus block targets sympathetic nerve fibers transmitting pelvic visceral pain. It provides long-lasting pain relief in various pelvic pain syndromes, including cancer-related and nonmalignant causes, with a safety profile when fluoroscopic guidance is used. This study aims to describe the experience and outcomes of a fluoroscopy-guided neurolytic block of the right superior hypogastric plexus in a patient with Nutcracker syndrome and Factor V Leiden mutation, focusing on analgesic efficacy and safety in the context of increased thrombotic risk.

A case report of a patient with confirmed Nutcracker syndrome and Factor V Leiden mutation, presenting refractory chronic pelvic pain. After multidisciplinary evaluation, a right superior hypogastric plexus block was performed under fluoroscopic guidance at the L4-L5 level with intravenous sedation. Contrast confirmed retroperitoneal needle placement, followed by injection of 2% lidocaine (160 mg/8 mL), 6% phenol (0.4 mL), and dexamethasone (8 mg/2 mL). Hemodynamic changes, bleeding, and pain (via numerical rating scale) were monitored perioperatively.

The patient reported significant pain reduction (from 8/10 to 3/10 on the NRS at one month), reduced analgesic requirements, and no thrombotic or procedural complications during three-month follow-up. The block was well-tolerated with no adverse events.

This case supports the superior hypogastric plexus neurolysis as a safe and effective therapeutic option for refractory pelvic pain in patients with Nutcracker syndrome and Factor V Leiden mutation expanding the armamentarium of regional anesthesia techniques in challenging clinical scenarios.

Chronic facial pain is often driven by various underlying mechanisms and can severely impact patients' quality of life. Peripheral nerve stimulation (PNS) emerges as a promising therapeutic option for managing chronic facial pain, offering potential relief where conventional treatments may fall short.

The patient, a 74-year-old male with a history of post-traumatic refractory facial pain, underwent PNS implantation targeting the Sphenopalatine ganglion (SPG) and auriculotemporal nerve (ATN). Patient consent was secured for the procedure and the case report. The patient received two successful diagnostic blocks, followed by a trial stimulation period of one week, in preparation for permanent implantation.

nt implantation. Results: The patient reported a significant reduction in headache frequency and intensity following the trial period. The VAS score decreased from 9/10 to 3/10. A decision to postpone definitive implantation was made, and at the 3-month follow-up, the patient continued to experience substantial pain relief with a VAS score of 2/10 and a reduction in headache episodes from daily occurrences to bi-weekly. Surveys were done to reassess the condition after two years with persistent results supporting evidence for long-term pain relief.

PNS with combined SPG and ATN stimulation can offer a viable and effective treatment option for patients with chronic facial pain. The substantial decrease in pain intensity and frequency and its persistence for months after trial removal highlight the value of shorter term implants not only in preparation for future longer lasting implants, but also as a possible standalone therapy. Further studies with larger cohorts are warranted to establish long-term efficacy and safety

Chronic postoperative pain is a common complication following breast surgery and significantly impacts patients' quality of life. A network meta-analysis has shown that regional techniques—such as paravertebral nerve block (PVB), pectoral nerve-2 block (PECS II), serratus anterior plane block (SAP block), erector spinae plane block (ESPB), rhomboid intercostal block, and local anesthetic infusion—provide significant relief from acute postoperative pain. However, data on their effectiveness in preventing chronic pain remain limited. This retrospective study aims to evaluate whether multimodal analgesia (MMA) can effectively reduce the incidence of chronic postoperative pain, providing new evidence to guide clinical pain management.

This single-center retrospective study extracted data from the hospital’s electronic medical record system, selecting records from October 1, 2023, to October 31, 2024. The study included adult patients who underwent breast surgery, with or without multimodal analgesia (MMA). MMA consisted of intravenous acetaminophen, opioids, NSAIDs, and nerve blocks (PECS I, PECS II, SAP, and PIFB). Postoperative pain was assessed using the Visual Analogue Scale (VAS) three to six months after surgery and analyzed using the Chi-square test.

A total of 103 patients who underwent breast surgery were included in the study, with 14 receiving MMA and 89 not receiving MMA. The proportion of patients without chronic postoperative pain was 71.4% in the MMA group and 64.0% in the non-MMA group. Chi-square test results showed a statistically significant difference (p = 0.027, < 0.05) (Table 1). These findings suggest that patients who received MMA had a significantly lower incidence of chronic postoperative pain compared to those who did not.

Our study suggests that multimodal analgesia (MMA) significantly reduces the likelihood of chronic pain in patients undergoing breast surgery.

The sacral hiatus at the base of the sacrum provides an entry portal to the epidural space. Local anaesthetic and steroid mixtures injected into the epidural space are used to provide pain relief in patients with lumbosacral radiculopathy.Although the gold standard is the fluoroscopic technique with the use of contrast, it is also associated with side effects such as radiation, side effects of the contrast, and expensive equipment required. The use of ultrasound for extraction of this procedure shows an increasing trend, it is simple to perform, and side effects from radiation and contrast are avoided.

We will describe a series of 30 patients with radicular pain, spinal stenosis and discopathy at the level of L4-L5 and L5-S1 . For patients in a prone position after appropriate disinfection of the field, under conditions of asepsis, with the use of Doppler, Ultrasound guided, we applied caudal stereoId injection. We applied 15 ml of NaCl 0,9% with 4 mg of Dexamethasone and 2 ml of Lidocaine 2% After the application, the patient in a prone position for 60 minutes. We monitor the level of pain through the Numeric rate score (NRS) before the block and after the application of the block for 1 hour, after 7 days and after 30 days.

20 patients had an improvement in their condition 1 hour after the application of the block and a reduction in pain score by 60%. The analysis made 7 days after the application of the block showed an improvement in the condition of 25 patients, with reduced pain score by 70% and easier movement. After 30 days of block application there was improvement and lower pain scores in 23 patients.

Ultrasound guided caudal steroid injection is safe and efficient simple procedure in pain treatment such as radicular pain, spinal stenosis and discopathy.

Chronic pelvic pain (CPP) is a frequent and often debilitating symptom of deep infiltrating endometriosis, with a complex pathophysiology involving nociceptive, neuropathic, and central sensitization mechanisms that remains a significant therapeutic challenge, often requiring a tailored, multidisciplinary, and multimodal approach. This case report illustrates the successful integration of pharmacologic, psychological, physiotherapeutic, and interventional strategies in the management of refractory CPP in a patient with rectovaginal endometriosis.

A 32-year-old female with a history of bipolar disorder and previous excision of a serous cystadenoma was referred to the chronic pain clinic in 2024 for CPP characterized by dysmenorrhea, dyschezia, dyspareunia, and dysuria. She had undergone laparoscopic resection of a 3 cm rectovaginal endometriotic nodule invading the hypogastric plexus in 2021, with intraoperative evidence of frozen pelvis. Despite ongoing hormonal suppression, a complex psychopharmacological regimen, pelvic floor physiotherapy, and psychological support, her symptoms persisted. After a positive diagnostic block, thermal radiofrequency ablation (RFA) of the superior hypogastric plexus was performed using three 90-second lesions on each side.

At four-month follow-up, the patient reported significant improvement in pelvic pain and dyspareunia, with no complications observed. The intervention allowed better functional outcomes and reduced interference with daily activities.

This case highlights the value of a multidisciplinary and multimodal strategy in managing complex CPP secondary to endometriosis. Thermal radiofrequency ablation of the superior hypogastric plexus proved to be a safe and effective interventional option within a broader multimodal strategy, offering meaningful symptom relief, particularly when unresponsive to conservative measures. The sustained clinical improvement observed reinforces the relevance of a multimodal and multidisciplinary strategy—combining pharmacologic, psychological, physiotherapeutic, and interventional modalities—as essential to managing complex and refractory pain syndromes.

Rheumatoid arthritis (RA) is a highly inflammatory systemic disorder. We aim to assess the effect of music therapy model Bonny Method of Guided Imagery and Music (BMGIM) on daily activities in patients with RA suffering from chronic pain.

This prospective randomized trial(NCT04380129) included adult patients with chronic pain due to RA, who were referred to our Outpatient Pain Clinic. After informed consent, participants were randomized (electronically) either in music therapy sessions (GIM group) or in music listening (control group). “Intervention” was defined as “a weekly session of listening to Helen Bonny's Caring program for 4 weeks”. The main outcome of interest was daily activity levels, as measured by the SF-36 questionnaire. Outcomes were recorded before the initiation of treatment and five weeks later. According to power analysis 37 participants per group were recruited. We used a repeated measures analysis to detect differences between the groups. Tests were two-tailed and statistical significance was established at 5% (p<0.05).

Our study identified no statistically significant differences in physical functioning (repeated measures t-test, p1 = 0.229, and Wilcoxon Signed-Rank test, p2 = 0.191) and somatic role (p1 = 0.093, and p2 = 0.108). Nevertheless, there was a significant improvement in bodily pain (p1<0.001,p2<0.001), general health perception (p1=0.03, and p2=0.016), vitality (p1<0.001,p2<0.001), social functioning (p1<0.001,p2<0.001), and mental health (p1<0.001,p2<0.001).

The analyses show significant improvements in health-related quality of life from the first to the second measurement. Notable enhancements were observed in Bodily Pain, Vitality, Social Functioning, and Mental Health, with General Health also showing improvement.

Rheumatoid arthritis (RA) is a highly inflammatory systemic disorder. We aim to assess the effect of music therapy model Bonny Method of Guided Imagery and Music (BMGIM) on daily activities in patients with RA suffering from chronic pain.

This prospective randomized trial(NCT04380129) included adult patients with chronic pain due to RA, who were referred to our Outpatient Pain Clinic. After informed consent, participants were randomized (electronically) either in music therapy sessions (GIM group) or in music listening (control group). “Intervention” was defined as “a weekly session of listening to Helen Bonny's Caring program for 4 weeks”. The main outcome of interest was daily activity levels, as measured by the SF-36 questionnaire. Outcomes were recorded before the initiation of treatment and five weeks later. According to power analysis 37 participants per group were recruited. We used a repeated measures analysis to detect differences between the groups. Tests were two-tailed and statistical significance was established at 5% (p<0.05).

Our study identified no statistically significant differences in physical functioning (repeated measures t-test, p1 = 0.229, and Wilcoxon Signed-Rank test, p2 = 0.191) and somatic role (p1 = 0.093, and p2 = 0.108). Nevertheless, there was a significant improvement in bodily pain (p1<0.001,p2<0.001), general health perception (p1=0.03, and p2=0.016), vitality (p1<0.001,p2<0.001), social functioning (p1<0.001,p2<0.001), and mental health (p1<0.001,p2<0.001).

The analyses show significant improvements in health-related quality of life from the first to the second measurement. Notable enhancements were observed in Bodily Pain, Vitality, Social Functioning, and Mental Health, with General Health also showing improvement.

Coxalgia is a common condition in patients over 45, prevalence increasing with age. Its etiology is diverse, including degenerative, inflammatory, infectious, or neoplastic causes. Radiofrequency (RF) targets the sensory innervation of the anterior hip capsule, particularly the articular branches of the obturator, accessory obturator, and femoral nerves. We present a case of severe coxalgia successfully managed with bipolar thermal RF after failure of conservative treatments.

A 68-year-old woman presented with progressive right-sided mechanical groin pain (VAS 8) of several years’ duration. Radiographic evaluation confirmed severe coxarthrosis. The patient had completed rehabilitation and first-line analgesic therapy. Despite orthopedic consultation, she declined surgical intervention and was referred to the Pain Unit for palliative management. A diagnostic block of the femoral, accessory obturator, and obturator nerves was performed under fluoroscopic and ultrasound guidance using 0.5% bupivacaine, resulting in complete pain relief for 36 hours. Bipolar thermal radiofrequency ablation was then scheduled. Under ultrasound guidance, the femoral neurovascular bundle was identified. Then RF needles (22G) were placed at the target sites under fluoroscopy. Thermal RF was applied for 2 minutes at 80°C after test stimulation.

The patient reported complete pain relief lasting 6 months. Upon symptom recurrence (VAS 6), the procedure was repeated one month later, achieving sustained improvement lasting at least one year.

Bipolar thermal radiofrequency is a safe and promising technique for the management of chronic coxalgia. Further studies are needed to compare its long-term efficacy versus monopolar RF approaches.

The ongoing war in Ukraine has resulted in major trauma resulting in limb amputations and tissue damage from blast injuries, shrapnel and gunshot wounds. Chronic pain including post-amputation pain and neuropathic pain not only impact on rehabilitation but also on the quality of life. The current situation in Ukraine has limited the use of interventional treatment options and systemic analgesics are limited by their side-effect profile. We looked at the use of non-invasive peripheral neurostimulation as a sustainable treatment option for managing the pain and facilitating rehabilitation.

45 of 51 patients of the initial cohort with different conditions mostly amputations and nerve injuries were subjected to a 30-minute stimulation using the Biowave device either as peripheral nerve or field stimulation using electrode pads or Biowraps. Pain scores immediately after treatment, at 24 and 48 hours were compared with baseline scores. Ease of mobilising with the prosthesis was also assessed. Patients were followed up for repeat treatments at the hospital or would be offered domiciliary treatment for ongoing pain relief and facilitate rehabilitation.

The average baseline pain score on VAS prior to treatment was 6.73 and immediately after the treatment was 3.46. Patients were followed up at 24 and 48 hours with VAS scores maintained at 4.59 and 5.00. The average duration of meaningful pain relief was 16.4 hours. Most amputees found it easier to mobilise using their prosthesis.

Non-invasive peripheral neurostimulation may be a efficacious, sustainable and cost-effective treatment option for managing battlefield injuries when resources and expertise are limited.

Chronic cystitis is a cause of chronic pelvic pain, often difficult to manage and with significant impact on quality of life. We propose the Erector Spinae Plane Block (ESPB) as a novel analgesic option for this condition, not previously reported in the literature.

We present the case of a 76-years-old hypertensive woman with a history of transuretheral resection of a bladder tumor. She developed chronic cystitis following BCG therapy, unresponsive to pharmacological treatment over a four-year period, including codeine, tramadol, paracetamol and pregabalin. CT scans, cystoscopies and urine cultures were unremarkable. An ultrasound-guided bilateral ESPB was performed at the L5 level under aseptic conditions. Each side received 10 ml of 0,25 % bupivacaine, 60 mg of triamcinolone, and 2 ml saline. Three weekly sessions were administered.

The patient experienced significant pain relief. At three months follow-up, recurrence of symptoms led to a repeat of the same protocol. Since then for the past six months, her VAS score has remained at 3/10. We propose that the ESP block may provide visceral analgesia by blocking sympathetic pathways, though variable paravertebral spread observed in anatomical studies may explain heterogeneous outcomes. Its precise mechanism remains uncertain.

Chronic pelvic pain due to cystitis remains a therapeutic challenge. This case suggests that ESPB may offer effective pain relief in selected patients, which represents an advantage given its high technical feasibility. Controlled studies are needed to confirm these findings.

Myofascial pain syndrome (MPS) is a common source of chronic musculoskeletal pain characterized by regional pain within the muscle, fascia or surrounding soft tissue. This syndrome is often managed through trigger point injections with local anesthetics. Ondansetron, a selective 5-HT3 antagonist primarily used as an antiemetic, has been suggested to exhibit local antinociceptive effects. The aim of this study was to compare the analgesic effectiveness of ropivacaine alone versus ropivacaine combined with ondansetron in patients with MPS

Forty people with a clinical diagnosis of MPS involving trigger points in the lumbar paraspinal muscles, quadratus lumborum and gluteal region were randomized into Group A, receiving injections of ropivacaine 0.2% alone and group B, receiving injections of ropivacaine 0,2% with ondansetron. Each trigger point was injected with 3 ml of the corresponding solution, with solutions for both groups visually identical. Pain intensity was assessed using the Numeric Rating Scale (NRS) before trigger point injection, at 72 hours, one week and two weeks post-injection

Both groups demonstrated reduction in pain scores following treatment. However, Group A exhibited significantly greater analgesic improvement at all follow-up time points, as measured by NRS scores, compared to Group B (p<0.001 at 72 hours and one week post injection and p=0.003 at two weeks post injection)

The addition of ondansetron to ropivacaine may antogonize its analgesic efficacy. This effect could be explained by a pharmacodynamic interaction, as ondansetron may modulate nociceptive neurotransmission through 5-HT₃ receptor antagonism and interfere with sodium channel-mediated local anesthetic action

Persistent pain after brachial plexus avulsion injury is often refractory to most treatments including analgesics, interventions and implantable devices for spinal cord and dorsal root ganglion stimulation. We report a case where we successfully treated longstanding pain following post-traumatic amputation at the upper third of the humerus, brachial plexus avulsion, phantom limb pain, post-head injury cerebral arachnoiditis, multiple rib fractures, scapular deformity and left diaphragmatic paresis following a RTA 12 years ago.

Patient was treated with an external neuromodulation device (Biowave corp) for 30 minutes as per protocol using two electrode pads and stimulation was well tolerated without producing any discomfort. Due to the history of brachial plexus avulsion injury, one lead was placed at T3-4 level left side of the spine and another at the inferolateral aspect of the left upper limb stump where he has maximum stump pain. Stimulation was well tolerated and could elicit it around the area of stump pain and the patient also reported that he could "feel the phantom limb normally" during the stimulation.

Prior to the procedure, the pain score was severe 8/10 on VAS and this was the average pain score he had been feeling for the past 12 years. Patient reported immediate improvement in pain during stimulation (VAS 1/10) and had sustained pain relief post-treatment (VAS 1/10) which lasted for 8 hours. Patient was offered repeat treatment on a domiciliary basis and we are monitoring the progress.

Targeted non-invasive external neuromodulation could be an effective treatment option for refractory neuropathic pain

Refractory angina refers to chest pain that persists despite optimal medical management and is not amenable to revascularization. Microvascular angina represents a particularly challenging and frequently underdiagnosed subtype. Spinal cord stimulation (SCS) is a minimally invasive, reversible neuromodulatory technique with demonstrated benefit in selected patients. We report the first case in our center of microvascular angina successfully managed with SCS after failure of all conventional therapies.

A 55-year-old man with microvascular angina and prior coronary revascularizations—including multivessel stenting and coronary sinus Reducer implantation—presented with persistent CCS class IV angina despite optimal pharmacologic treatment. He required frequent emergency visits and hospitalizations for recurrent chest pain, with partial relief from intravenous nitrates and transdermal opioids. Following a favorable home-based TENS trial, SCS was indicated. Under local anesthesia and sedation, an epidural lead was placed at L2–L3 and advanced to C7 under fluoroscopic guidance. A subcutaneous pulse generator was implanted.

The postoperative course was uneventful. Minor programming adjustments were needed to optimize stimulation. The patient reported sustained improvement in anginal symptoms, experiencing fewer and less intense episodes. He discontinued transdermal opioids and reduced overall medication use. At follow-up, his functional capacity and independence had markedly improved. No complications were observed, and symptom control remained stable.

SCS appears to be a safe and effective therapeutic option in selected cases of refractory microvascular angina. This case highlights the potential role of neuromodulation within a multidisciplinary approach to cardiovascular pain management.

Low ejection fraction and poor perfusion can not only delay wound healing but can also result in ischaemic pain in the foot. We report a case of successfully managing neuropathic pain and improving perfusion thus promoting wound healing using repeated treatment with Biowave external neurostimulation in a patient who had a non-healing trophic ulcer of the foot following mine-blast injury 10 months ago and complicated by deep vein thrombosis and dilated cardiomyopathy.

Patient was initially treated with a 30-minute Biowave neurostimulation as per protocol twice a day as per protocol and from day 14 onwards this was increased to three times a day. Pain scores were monitored with VAS and other quality of life indicators were monitored over a 16-day period. Perfusion was measured using thermography and progress of wound healing was also documented. General improvement reported by the patient were also noted.

Baseline VAS was 9/10 preventing independent mobilisation. VAS was reduced to 5/10 after the first stimulation and the effect lasted more than 8-10 hours. Following twice daily stimulation, VAS was reduced to 0/10 after three days. No nocturnal pain was reported after two days improving sleep hygiene. Patient resumed independent mobilisation after five days. Improved perfusion and enhanced granulation were observed, and no systemic analgesia was required for maintenance analgesia; there was reduction of rescue analgesia for wound dressing.

Repeated treatment with Biowave external neurostimulation not only improves neuropathic pain but also facilitates wound healing of trophic ulcer in conditions of poor ejection fraction and perfusion.

Myofascial Pain Syndrome (MPS) is characterized by fascial thickening, stiffness, and impaired sliding of the fascial planes, primarily due to biochemical alterations such as increased viscosity of Hyaluronic Acid (HA). These changes hinder normal fascial mobility and contribute to persistent nociceptive input. Dynamic ultrasound (echodynamic imaging) offers a non-invasive method to assess these biomechanical alterations in real time.

We report the case of a 55-year-old male with chronic dorsolumbar pain (D8-D12) following D4-pelvic arthrodesis. Initial echodynamic imaging revealed a thickened, hyperechoic, and rigid fascia with poor gliding of muscle layers, consistent with myofascial stiffness. This baseline served for pre-treatment evaluation. A fascial block using 30 ml of 42 °C saline solution was administered under ultrasound guidance. Follow-up assessments were conducted at 15, 30, 60, and 90 days post-intervention.

Echodynamic evaluations showed progressive improvement in fascial mobility. The most significant finding was the appearance of the “Binary Band” sign, indicative of fascial layer separation and restored sliding capacity—absent at baseline. Clinically, the patient experienced a marked reduction in pain (NRS from 8 to 2), improved movement, and reduced muscle hypertrophy.

Dynamic ultrasound is a key tool for diagnosing and monitoring MPS. The combined evaluation of fascial layer gliding and the Binary Band sign offers objective, reproducible indicators of treatment efficacy, reflecting structural and functional fascial recovery. Moreover, ultrasound is a first-line, easily accessible, and low-cost imaging modality for musculoskeletal assessment, suitable for use in outpatient settings.

Post-traumatic neuropathic pain with allodynia and hyperpathia is very debilitating and treatment with systemic medications is often frustrating due to poor efficacy and unacceptable side-effects. We report the case of a medical student with persistent allodynia and hyperpathia of her dominant upper limb following multiple fractures of the humerus and olecranon with ulnar nerve injury treated successfully with a single application of external neurostimulation (Biowave) enabling her to touch the affected area and apply topical menthol cream for symptomatic relief.

Patient was treated with external neuromodulation (Biowave) for 30 minutes as per protocol; one electrode was placed proximal to the elbow on the ulnar aspect and the distal electrode was placed on the ulnar aspect of the wrist. Within minutes of the stimulation the patient was able to touch the area of allodynia without any discomfort. The stimulation was well tolerated.

Pre-procedure, the pain score was 8/10 on VAS. Patient reported immediate improvement in pain at 5 minutes during stimulation (VAS 0/10) and had sustained pain relief post-treatment (VAS 0/10) lasting for 72 hours. Though there was some residual pain, patient was able to use topical 2% menthol cream four times a day. Patient was also able to do active wrist extension which was previously not possible due to pain. We have offered repeat Biowave treatment if required if there is return of symptoms.

External neurostimulation with Biowave could alleviate neuropathic pain and facilitate the use of topical treatment for managing localised neuropathic pain avoiding systemic side-effects including cognitive dysfunction.

Percutaneous cervical discectomy is a minimally invasive procedure for cervical disc herniation, but esophageal and tracheal injuries remain a concern. This study evaluates the effectiveness of a refined technique incorporating orogastric tube (OGT) and endotracheal tube (ETT) adjustments to mitigate these risks.

A retrospective analysis was conducted on 157 patients who underwent percutaneous cervical discectomy between 2023 and 2024. A standardized technique involving endotracheal (ETT) and orogastric (OGT) tubes was used. Gentle palpation and adjustment of the tubes provided tactile feedback to help guide needle placement safely into the disc space under fluoroscopic control. The procedures were performed at the following levels: C3-C4 (1.3%) C4-C5 (12.3%) C5-C6 (39.8%) C6-C7 (16.6%) Two combined levels (12.3%) The mean age was 47.0 ± 12.4 years, with 44.6% male and 55.4% female patients (M:F = 7:9). Patient demographics, surgical outcomes, and complication rates were analyzed.

The technique ensured accurate localization and safe access to the cervical disc space in all cases .Despite potential risks, no esophageal or tracheal injuries were observed, resulting in a 0% complication rate. Additionally, no cases of dysphagia, hoarseness, or airway compromise were recorded.

The use of OGT and ETT as anatomical markers in percutaneous cervical discectomy significantly enhances procedural safety by eliminating esophageal and tracheal injuries. Compared to previously reported complication rates, this technique demonstrated a superior safety profile with a 0% injury rate. These findings support the continued use of this approach to reduce risks in anterior cervical spine procedures. Further studies with larger cohorts are recommended.

Failed Back Surgery Syndrome (FBSS) is a chronic condition characterized by persistent pain following back surgery, with an incidence ranging from 10–40% after lumbar procedures. The etiology includes nerve injury, spinal stenosis, facet disease, and surgical scarring, making it difficult to treat with conventional therapies. Spinal cord stimulation (SCS), a neuromodulation technique, has emerged as a promising treatment over the past five decades. SCS inhibits pain pathways and influences supraspinal circuits and peripheral blood flow. Despite advances, selecting optimal patients for SCS remains challenging. Given the complexity of FBSS and resistance to standard treatments, novel neuromodulation devices such as Medronic Inceptiv may be a possible therapeutic option.

Four FBSS patients with prior unsatisfactory spinal cord stimulator outcomes were treated with Medronic Inceptiv. Pain intensity was assessed using the Visual Analog Scale (VAS), and neuropathic pain symptoms were evaluated before and after treatment. Patient-reported outcomes were collected during follow-up visits.

All four patients demonstrated significant pain reduction after Medronic Inceptiv implantation, reporting a satisfactory decrease in VAS scores, alongside marked improvements in neuropathic pain symptoms. No adverse events were reported during follow-up. These results indicate a notable clinical benefit of Medronic Inceptiv in this difficult-to-treat patient group.

Despite the limited sample size, this case series highlights the potential of Medronic Inceptiv to be a new, promising effective therapeutic option for FBSS patients dissatisfied with previous spinal cord stimulation.