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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Radiofrequency (RF) is the main treatment for patients suffering from low back pain originating in the lumbar facet joints; since there is lot of variability in performing the technique, our objective is to analyse it current situation in Spain.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Results represented as tables Figs 1-3.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ileus is an important contributor to morbidity after colorectal surgery. Ultrasound may be used to detect early dysfunction by imaging of the stomach and small bowel. The aim of this feasibility study was to identify if gastric ultrasound could detect ileus by demonstrating delayed gastric emptying.

Prospective, non-randomised, observational cohort study, using a curvilinear ultrasound probe. Imaging was performed in the epigastrium, in a parasagittal orientation to obtain a cross-sectional area (CSA) of the gastric antrum. Baseline scanning was performed, followed by ingestion of 200mls of water. Measurements of CSA were performed at 20 and 40 minutes to assess change in volume of the stomach, as well as a single assessment of small bowel peristalsis. Feasibility outcomes were collected including recruitment rates, and adequacy of views.

27% of patients had GI dysfunction. On D1, the gastric antrum CSA was significantly larger in the dysfunction group at 20 minutes, 8.3cm2 (4.7) vs. 12.4cm2(4.1), p=0.044 and at 40 minutes 6.0(3.6) vs. 8.0(2.4), p=0.05. The ability of a D1 post op US scan to detect GI dysfunction was best at a cross sectional area of 10cm2, which yields a sensitivity of 71% and a specificity of 76%. The negative predictive value is 89%, with a positive predictive value of 50%.

GI dysfunction after major abdominal surgery can be predicted by a day 1 gastric ultrasound after water ingestion. Gastric US is better at predicting those patients who do not have GI dysfunction.

The External Oblique Intercostal block (EOIB) provides analgesia to the upper midline and upper lateral abdominal wall. This study assesses the efficacy of this block in patients undergoing cholecystectomy with a right subcostal incision.

We describe fourteen elective open cholecystectomy cases where a right external oblique intercostal plane block (EOIB) was performed with 30mL of 0.33% ropivacaine after the induction of general anesthesia. During surgery, all patients received 3µg/kg of Fentanyl and an additional 50µg bolus as needed, 30mg/kg Metamizole, and 100mg Ketoprofen. For postoperative nausea and vomiting (PONV) prophylaxis, Ondansetron 0.15mg/kg and Dexamethasone 0.15mg/kg were administered. Postoperative analgesia was maintained with 1g IV Metamizole 8/8h. Opioid consumption, complications, and patient satisfaction with analgesia were recorded within the first 24h. Demographics and intraoperative profiles were collected (Table 1). Consent was obtained from all patients.

Upon PACU admission, over 75% of patients had a VAS of less than 3, and the highest pain score was observed at 12 and 24 hours postoperatively, which corresponds to the block’s analgesia duration (Table 2). The postoperative opioid consumption was relatively low overall with only 4 patients requiring one time use of Tramadol 100mg IV. Patient satisfaction with analgesia was high, as indicated by 70% of patients providing a satisfaction score of 10/10. No cases of PONV or block-related complications were observed.

Our findings suggest that EOIB reduces pain scores and opioid consumption for Kocher surgeries and is an effective part of a multimodal analgesia strategy

Minimally invasive cardiac surgery (MICS) has emerged as a promising approach for cardiac procedures, improving patient outcomes. However, postoperative pain management remains a significant challenge in this field. Various regional anesthesia techniques have been investigated with the erector spinae plane block (ESPB) being one of the relatively recent advancements. Our aim is to compare the efficacy of this block with a control group in patients undergoing MICS.

PubMed, EMBASE, and Cochrane were searched for studies comparing the ESPB to control (non-block group). The outcomes included opioid consumption, postoperative duration of mechanical ventilation, and intensive care unit (ICU) and hospital lengths of stay. RevMan 5.4 analyzed data.

The present study systematically analyzed a total of six studies encompassing a sample size of 717 patients, with 43.2% of them undergoing the erector spinae plane block (ESPB). Our findings revealed that the implementation of ESPB yielded a statistically significant reduction in the duration of mechanical ventilation when compared to the control group (Figure 1). Conversely, no significant differences were observed between the ESPB and control groups in relation to opioid consumption (Figure 2). Furthermore, there were no significant disparities detected between the groups concerning the lengths of stay in the intensive care unit (ICU) and hospital (Figure 3).

Based on our findings, it can be inferred that the implementation of the ESPB may effectively decrease the duration of mechanical ventilation. However, in order to draw more comprehensive conclusions, further investigations involving a larger number of patients are warranted.

In 2021 we developed the Regional Anaesthetic Alert Bracelet Project (RA-AB)(1) in response to joint recommendations from OAA/AoA(2).The RA-AB helps to monitor recovery of motor function after neuraxial block and prompts timely escalation of care, if recovery of straight leg raise is delayed beyond four hours.This safety initiative has been successfully adopted in over fifty Trusts in UK but predominantly in the obstetric population.Our aim was to introduce the RA-AB in non-obstetric patients receiving regional blocks in our Trust.Additionally,to assess the impact on nursing staff knowledge and to update the Toolkit(3) with useful resources to assist other Trusts in their implementation of the project.

Pre-implementation questionnaire to nursing staff (theatre,recovery, post-operative ward).Nursing education provided via a PowerPoint presentation and posters. Trial of RA-AB for 2 months which included inclusion of bracelet placement at WHO checkout with a verbal hand over of time to straight leg raise between nursing teams. Post-implementation questionnaire.

We demonstrated a 3-fold improvement in recovery staff knowledge regarding the serious complications following a central neuroaxial block along with qualitative feedback that RA-UK increased patient safety and improved communication.

We have demonstrated that the RA-AB increases staff knowledge of serious neurological complications after neuraxial block in the non-obstetric population. This population is more heterogeneous and challenging than the obstetric population. Empowering nursing staff through education is of the utmost importance to the success of this project. The updated toolkit provides similar branding and infographics to hopefully allow the RA-AB to become synonymous with best practice in regional anaesthesia.

Intracranial hypertension is a serious complication after an epidural blood patch to treat post dural puncture headache (PDPH). The authors describe a clinical case of intracranial hypertension post epidural blood patch (IHPEBP) to highlight the importance of the differential diagnosis of PDPH after performing a neuraxial technique.

33-years old female, ASA II, admitted for elective cesarean section (CS). The procedure was uneventful under anesthetic combined spinal-epidural technique. There was no background history of gestational hypertension, neurological pathology, vascular malformations or cranioencephalic trauma. At 24h post CS, the patient presented a frontal and occipital headache at orthostatism, buzzing and photophobia, unresponsive to conservative analgesic. At 72 h post CS, the symptoms persisted, and an epidural blood-patch was performed, uneventful and with immediate relief of symptoms. Patient was discharged the day after.

Four days after hospital discharge, the patient returned to the emergency department, presenting headache relapse, without postural influence and visual disorders, with onset on that day. The venous cerebral CT scan revealed a "thin subdural hematic lamina", with no other significant findings. She was evaluated by Ophthalmology and Neurology, who considered the IHPEBP to be the most likely cause of the headache.

The lack of more widespread recognition of this condition is probably caused by a superficial similarity of presenting features: headache is the predominant symptom experienced by patients with IHPEBP and patients with PDPH. For a correct differential diagnosis, additional diagnostic tests and a multidisciplinary discussion should be considered. Lack of familiarity with this complication can result in misdiagnosis.

Vaginismus is a condition characterized by an aversion to vaginal penetration due to actual or anticipated pain. This can pose challenges during pregnancy and delivery.

We report a case of a 25-year-old pregnant woman from Bangladesh with severe vaginismus admitted in the labor unit for induction at 41 weeks of gestation. It should be noted that the patient wished to experience a eutocic delivery. Therefore, induction was initiated with endovaginal prostaglandin under fetal monitoring, despite the background. A few hours later, the patient started to develop contractions and did not tolerate further obstetric evaluations due to severe pain on vaginal examination. After a multidisciplinary discussion, we decided to proceed with epidural anesthesia before any further examinations. Ropivacaine 0.5% was used to produce analgesia and motor blockade ate S2-S4 level to reduce spasming. The remaining vaginal evaluations were uneventful. A trial of vaginal labor was attempted, but eventually induction failure was presumed, and the patient underwent cesarean section under epidural anesthesia. Postoperative analgesia included intravenous paracetamol and ketorolac and fixed epidural boluses of ropivacaine. Maternal and fetal outcomes were favorable, and the parturient reported satisfaction with the adopted approach. Recent improvements in labor epidural analgesia have prioritized pain relief without motor blockade. Vaginismus increases the risk of requiring instrumentation, or cesarean delivery, as well as perineal and vaginal trauma.

Early epidural analgesia with some degree of motor blockade can be a valid approach in the management of the laboring woman with vaginismus, facilitating vaginal delivery, reducing complications, and ensuring patient satisfaction.

Intractable cancer-related chest wall pain is a challenging condition that significantly affects the quality of life for patients with advanced cancer. Traditional pain management approaches, such as opioids and adjuvant medications, may not provide adequate relief in some cases. This case report describes a 21-year old patient with intractable cancer-associated chest wall pain who was treated with intercostal nerve neurolysis. The patient was previously diagnosed with a rapidly growing unresectable Ewing sarcoma of the 7th rib and admitted for uncontrolled pain despite maximum tolerated dose of opioid and coanalgesic medication.

First, a diagnostic ultrasound-guided nerve block of the 6th through 8th intercostal nerves was performed, using 1 mL of 2% lidocaine per level. Within 30 minutes there was a reduction in over 90% of the pain, deeming the block positive. This was followed by chemical neurolysis of the 6th through 8th intercostal nerves using 2 mL of 80% alcohol per level, under ultrasound guidance.

There was significant pain relief. No adverse events were observed. The patient was discharged 36 hours later with minimal pain. At one week follow-up the patient had persistent pain control with no need for rescue medication. Monthly follow-up was planned to evaluate long term analgesia.

Although further research is needed to ascertain its efficacy and safety, current evidence suggests that intercostal nerve neurolysis can be a valuable tool in the multidisciplinary management of intractable cancer-related chest wall pain, offering relief and improving the quality of life for these patients.

Artificial intelligence (A.I.) is now an integral part of our day-to-day life. Starting from voice recognition on devices to automated chat box responds AI has innovated our households as well as work. There are possibilities of AI to revolutionize future practice of ultrasound guided regional anesthesia (USRA) through supporting ultrasound scanning. This could help with improved patient outcomes, interpersonal variability, and time requirement. we intend to review the current literature in AI practiced and established in UGRA as well as look at the new advances.

We reviewed articles published in last 6 years about AI in Ultra sounded regional anesthesia as well as needed cross references for better understandings of the innovative topic involving. Quality of the studies in terms of RCT, Comparative analysis observational and cohort were individually assessed according to the methodology followed (total of 14) and metanalysis (1).

The results were elaborated in regard to specific AI technology used: Color Over lay (ScanNavTm) overlay, Deep learning, CNN network (needle tracking) and outcome utility discussed individually. Also AI utility in Medical education of Tranee for USGRA was assessed as a component of the outcome measures.

AI in USGRA review demonstrate a steep improvement in patient outcome and procedural ease with use of AI. Also, as a tool to administer step to step feedback in medical training for peripheral nerve block. It Tremendously improved US image correct identification and enhances needle tracking. Hence reducing inadvertent Nerve injury, vascular trauma or systemic toxicity of local anesthetic medication.

Ultrasound-guided obturator nerve block is performed to prevent adductor muscle spasm during transurethral resection of bladder tumors. The aim of the study was to compare the effectiveness of a single-proximal injection protocol versus a double-distal injection protocol for obturator nerve block.

A total of 60 obturator nerve blocks were conducted (NCT05540847) and the patients were divided into two groups. The first group received an ultrasound-guided single injection for obturator nerve block (proximal group), while the second group received a double-injection technique for obturator nerve block in transurethral resection of bladder cancer under spinal anesthesia (distal group). In proximal group, the local anesthetic solution (10ml bupivacaine 0.25%) was administered into the interfascial plane between pectineus and obturator externus muscles. In distal group, first injection was administered into the interfascial plane between the adductor longus and adductor brevis muscles and the second injection between the adductor magnus and adductor brevis muscles (10ml bupivacaine 0.25% for each). The grade of adductor muscle spasm, clinical effectiveness rate, duration of the block procedure, and any complications were documented. Patients who experienced grade four adductor spasms were transferred to general anesthesia.

The number of patients who did not experience adductor muscle spasms in the proximal group was significantly higher than in the distal group. The procedure time was shorter in proximal group.

There was no significant difference in clinical effectiveness between the two groups. The proximal group which provşdes nerve block with less local anesthetic, maybe a strong alternative to the distal technique.

Hip fractures pose challenges in patient management, especially when surgical risks outweigh benefits. Inadequate analgesia from conservative treatment options prompted the development of new procedures targeting hip capsule denervation. We aimed to evaluate the efficacy of chemical neurolysis as a conservative treatment for hip fractures, within our department's protocol.

Patients who were deemed inoperable by either the orthopedists or anesthesiologist were evaluated for eligibility criteria and informed consent was obtained. A diagnostic block was performed under ultrasound guidance using 5 mL of 2% lidocaine in the pericapsular nerve group plane. With the needle in situ, the block's efficacy was evaluated by performing flexion, internal and external rotation of the hip joint. If the block was deemed positive, the needle's location was confirmed, and 6 mL of 99% alcohol was administered. Prior to needle removal, 1 mL of local anesthetic was flushed through the needle.

During the one-year period from May 2022 to May 2023, a total of five patients (aged 55 to 96) underwent the procedure. All were previously unable to ambulate. At the 1-day follow-up, one patient experienced pain, which resolved by the 5-day evaluation. None of the patients reported pain at the 5-day follow-up, and all were discharged pain-free. There were no reported adverse effects. Follow-up was scheduled in outpatient orthopedic consultations.

Chemical neurolysis seems to provide effective and safe conservative treatment for hip fractures, offering reliable analgesia for non-surgical candidates. Effective collaboration between orthopedic and anesthesiology teams was vital for high-quality patient care.

We aimed to evaluate pain scores after ganglion impar block and caudal epidural steroid injection in patients with chronic anococcygeal pain syndrome, who did not respond to conservative treatment.

The information of 31 patients with anococcygeal pain, who underwent Ganglion impar block and caudal epidural steroid injection was retrospectively reviewed. G.impar block (6mL of bupivacaine %0.125+methylprednisolone 40mg mixture) and caudal steroid injection (7mL of bupivacaine %0.125 +methylprednisolone 40mg mixture) were applied to all patients. After one month, G. impar pulsed radiofrequency(pRF) (6minutes at 42degrees) and caudal injection (7mL of bupivacaine %0.125+methylprednisolone 40mg mixture) were applied to patients who temporarily benefited from the procedure. All procedures were performed under fluoroscopy. Demographic data, etiology of pain, and visual analog scale(VAS) scores before and after the procedure were obtained from patient records.

A total of 31 patients of which 5 males(16%) and 26 females(84%) were included in the study. Average age was 41.5 years. Etiology was trauma in 20 patients, surgery in 2 patients, gastrointestinal disease in 2 patients, vaginal delivery in 1 patient, and idiopathic in 5 patients.The mean score of the VAS before the procedure was 7.74. After Impar and caudal block with pRF, average VAS score was decreased to 1.48. 21 patients became pain-free after the procedure, which remained for an average of 52.4 days (2-1840 days). 2 patients reported transient paresthesia and 1 patient reported transient distal edema after the procedure.

G.İmpar block,pRF and caudal epidural steroid injection are effective procedures for patients with anococcygeal pain without significant complications.

This service evaluation project assesses anaesthetic technique efficiency and postoperative analgesia, comparing general anaesthesia versus axillary brachial plexus block performed for plastic hand trauma surgery.

Retrospective data were collected from electronic records between June 2020 and May 2022. Fifty-two patients who received axillary brachial plexus were randomly matched with an equal number of patients who received general anaesthesia for plastic hand trauma surgery. The measured outcomes were (1) anaesthetic time, (2) postoperative opioid consumption in 24 hours expressed as oral morphine dose equivalence, (3) time spent in the recovery room and (4) time to hospital discharge. Data were analysed using the Mann-Whitney U test.

The table below summarises measured outcomes comparing general anaesthesia to axillary brachial plexus block for plastic hand trauma surgery.

Although general anaesthetic time was shorter than axillary brachial plexus block time, patients who received brachial plexus block spent less time in recovery and required less opioid analgesia. This project could support introducing block rooms to optimise theatre efficiency.

Determine the incidence, characteristics, impact, and risk factors associated with persistent incisional pain.

Patients who were 45 years of age or older who underwent major inpatient noncardiac surgery. Data were collected perioperatively and at 1 yeat after surgery to assess for the development of persistent incisional pain.

At one year, from 3.3% to 3.6% patients reported persistent incisional pain. Several demographic and perioperative factors have been identified to be associated with increased risk of persistent pain. Risk factors associated with this problem were young and females patients, tobacco use, coronary artery disease, history of chronic pain, Asian ethnicity, type of surgery, consumption of NSAIDs and cyclooxygenase-2 inhibitors before surgery, insulin not taken before surgery, postoperative PCA use and postoperative continuous nerve block use. Endoscopic surgery were associated with a lower risk of persistent pain. 81% of patients reported one or more features of neuropathic pain characteristics and 85.1% reported interference of pain on some aspect of their daily living. 52.7% of patients with persistent incisional pain reported taking a pain medication.

Persistent pain is unfortunately a common and problematic complication after surgery and it continues to be a significant source of distress, occurring in approximately one in thirty adults. At one year, from 3.3% to 3.6% patients reported persistent incisional pain. It is fundamental identify the incidence, characteristics, impact, and risk factors associated with the development of persistent incisional pain so that it results in significant morbidity, interferes with daily living, and is associated with persistent analgesic consumption.

Diabetic peripheral neuropathy (DPN) is a commonly occurring and incapacitating complication of diabetes, frequently leading to considerable discomfort and reduced patient well-being. The existing therapeutic modalities for DPN are constrained in their efficacy, prompting the exploration of spinal cord stimulation (SCS) as a viable alternative for pain mitigation. This investigation aims to provide a current synopsis of the latest literature on the effectiveness and safety of SCS in managing DPN.

The study employed a literature search approach, utilizing the most current and pertinent sources. The analysis incorporated studies published after 2017, comprising clinical trials, observational studies, and position statements. The study centered on the effectiveness, safety, and comparative analysis of various spinal cord stimulation (SCS) systems employed in treating diabetic peripheral neuropathy (DPN).

Recent findings indicate that Spinal Cord Stimulation (SCS) is a secure therapeutic alternative for individuals diagnosed with Diabetic Peripheral Neuropathy (DPN). Several studies have reported noteworthy reductions in pain and enhancements in quality of life. The scholarly literature underscores the significance of selecting the suitable SCS system following the specific requirements of each patient, given that different systems present various advantages and disadvantages.

In conclusion, SCS exhibits potential as a viable treatment alternative for DPN, providing pain alleviation and enhanced quality of life for individuals who have experienced limited efficacy from conventional therapies. Prospective studies are needed to optimize spinal cord stimulation (SCS) parameters, determine predictors of treatment response, and assess long-term outcomes to enhance the effectiveness of SCS in managing DPN.

Background: Data regarding the ‘opioid epidemic’ (chronic opioid use and related admissions secondary to inappropriate prescribing) stems primarily from North American literature. The impact of opioid prescriptions leading to long-term use/dependence has also been assessed in the United Kingdom. Aim: To assess the number of opioid-naïve patients (>=18 years of age) who were discharged on opioids (codeine, oxycodone, tramadol and morphine) by the general surgery department in an NHS trust and to assess for variables that correlate with discharge on opioid medication.

Methods: Records of opioid-naïve adult patients discharged by Buckinghamshire Healthcare NHS Trust General Surgery Department between 1st September 2022 and 30th September 2022 were reviewed and data regarding demographics, management and discharge medications was gathered. Descriptive, Chi2 and tetrachoric (TC) statistical analyses were conducted.

Results: 394 patients were discharged in September 2022. 193 male and 201 female. The most common diagnoses were abscess (57), cholelithiasis/cholecystitis (51) and hernia (41). 75 admissions were elective and 319 emergency. 219 cases were managed surgically and 175 conservatively. 48 surgical cases involved laparotomy and 92 laparoscopy. 98 patients were discharged with opioid analgesia (88 codeine, 2 oxycodone, 3 morphine, 5 tramadol). Chi2 testing showed an association between discharge on opioids and admission type (p<0.001, TC=-0.96, correlating with emergency), management (p=0.027, TC=-0.637, weakly correlating with conservative), and surgery type (p=<0.001, TC=-0.97, correlating with laparotomy).

Conclusion: A significant portion of surgical patients are discharged on opioids. Future studies will examine for continued opioid use 6 and 12months post-discharge.

In our study, our aim is to examine the effects of modified thoracoabdominal nerve (M-TAPA) applied for postoperative analgesia in patients who had major intraabdominal surgery on the postoperative pain score, the change in the postoperative total opioid requirement and the side effects.

We separated the patients into two groups as M-TAPA applied group and control group. In group M-TAPA, M-TAPA block was performed bilaterally with 20 mL of 0.2% bupivacaine under ultrasound guidance at the end of surgery. No block was performed in the control group. Patients were administered morphine through patient controlled analgesia (PCA) pump with a bolus dose of 1 mg, 15 min lockout interval. The postoperative pain scores (the numeric rating scores (NRS)), total opioid consumption in the first 48 h, antiemetic consumption and opioid related side effects were recorded.

A total of 43 patients were included in the study. Pain scores (at 2.,6.,12.,24.,36. hours) were significantly lower in group M-TAPA than in the group control (p<0.001). The total amount of morphine consumption in the first 48 h was lower in group M-TAPA than in the group control (M-TAPA 21,13± 6,56; IV PCA 61,70 ± 11,42) (P<0.001). There were no significant differences between the groups in terms of side effects and rescue treatment (p>0,05).

Bilateral ultrasound-guided M-TAPA block provides reduced postoperative pain scores, effective analgesia and decreased opioid consumption in patients undergoing major abdominal surgery.

Abdominal hysterectomy (AH) is associated with significant pain. Adequate pain control is essential for improving postoperative outcomes. Although PROSPECT guidelines, dating back to 2006, do not recommend continuous wound infusion (CWI) for AH, the references cited in the guideline used the subcutaneous space as a site for infusion. However, the recent PROSPECT guideline for cesarean section considers CWI effective for analgesia. Given the similarity in incision and surgical site, we conducted a randomized controlled trial to compare deep CWI with transversus abdominis plane (TAP) block, the most commonly used regional anesthesia technique for abdominal surgeries, for AH.

After ethical committee approval (71.22) (NCT05686382), we started to enroll patients scheduled for AH with Pfannenstiel incision. The intervention group received 48 hours of continuous ropivacaine 0.2% infusion through a prefilled fixed rate pump (Ropivacaine ReadyfusOR - BioQ Pharma) via a multi-holed catheter placed along the incision line between transversalis fascia and parietal peritoneum. The control group received a bilateral TAP block with ropivacaine 0.5% 20 ml. We recorded data on pain scores at rest and in motion, opioid consumption, and postoperative side effects.

Preliminary data from the first ten cases showed differences in pain scores (NRS) in favor of the CWI group as shown in tab.1. No differences emerged for other outcomes so far.

Preliminary data showed CWI as not-inferior to the TAP block for AH for postoperative pain control. We believe that final data will confirm this result.

Osteoporotic vertebral compression fracture (OVCF) is a problem causing incapicating pain, disability and mortality. Percutaneous Vertebroplasty (PVP), a minimally invasive procedure, has resulted in immediate pain relief with decreased morbidity. Primary aim was to evaluate the quality of life (QOL) by the RMDQ (Roland- Morris disability questionnaire) Score and pain relief by 11 points NPRS (Numeric Pain Rating Scale) and vertebral height restoration and Wedge angle measurements after Percutaneous Vertebroplasty (PVP)

This prospective longitudinal interventional study was conducted on patients with low back pain due to OVCF. These patients were managed by PVP and followed at one week, one , three and six months for improvement in quality of life (QOL) by RMDQ Score and pain relief using the NPR scale. The pre and post-vertebroplasty wedge angle and vertebral height at one week and six months were also compared by pre and post-vertebroplasty lateral view skiagrams.

Twenty-four patients were included. The RMDQ score showed a statistically significant difference in post-PVP at one week (p=0.044), one (p=0.031), three (p=0.022), and six months (p=0.018). There was a statistically significant difference in the NPRS at six months showing drastic pain relief after PVP. The mean wedge angle (20.5±2.07) measurement was reduced with a statistically significant increase in anterior body height restoration from pre-PVP to six months. There was no significant change in height at the middle and posterior columns compared to Pre-PVP height.

PVP is safe, minimally invasive pain intervention (MIPSI) for OVCF with improved QOL and restoration of vertebral height.

The evaluation of the postoperative acute pain (PAP) is sometimes difficult in children more-than-six-years- old, such as the visual analogue scale (VAS). The objective of this study is to assess the existence or not of a difference in the scores obtained by two evaluation scales at the same time.

This is a prospective study which includes children who had limbs surgery. In order to identify patients “difficult to be evaluated” during the first 24 hours of the post-operative phase at : H0, H4, H8, H12, H18, H24. self-assessment of pain combined with the behavioral pain assessment scale were proposed at the same time to patients (VAS and FLACC ¬[Face Legs Activity Cry Consolability]). The data was analyzed by the SPSS “20” software program. The threshold of significance was 5% (P < 0,05). An intra-category correlation test was realized between the two above-mentioned scales.

355 patients were included in this study. The average age was 9,29 ± 4,13 years. The average of the postoperative pain scores were 1,03 ± 1,61 for the VAS and 0,48 ± 1,23 for the FLACC. We also found that the intra-category coefficients were stated between r = 0,79 and 0,81 with a very good reproducibility of the two scales.

These results sustain the possibility of using the FLACC scale as reliable instrument in case of doubt regarding the VAS obtained score in more-than-6-years-old children.

Percutaneous disc decompression with laser is indicated in cases where increased intradiscal pressure is identified as the main etiology of discogenic low back pain. These techniques include percutaneous disc decompression with euthermic discolysis with Holmium YAG laser (Discolux®). This reduces the compression of the nervous structures and decreases the stimulation of pain receptors, thus achieving an analgesic effect. Technique is indicated in patients that keep the nucleus pulposus hydrated (Pfirmann I-III). Extruded or non-contained hernias are excluded. Our aim is to describe the results obtained from the 18 cases that underwent percutaneous disc decompression with euthermic laser.

We followed all the patients scheduled for laser euthermic discolysis (Discolux ®) from June 2022 to May 2023 in our center. We asked the participants about their VAS (Visual Analogue Scale) before and after the intervention. Afterward, we group them according to their Pfirmmann classification. The results are presented below.

The technique was performed in a total of 18 patients, all of them diagnosed with lumbar hernia by magnetic resonance. In the corresponding tables, we showed the collected data.

Limitations coming from the type of study are clear, but as we can see in the results, it can be a promising technique if the indication is correct, also we find a tendency depending on the time passed after the technique. We find reductions in pain by 46%. Although more studies are necessary to prove the technique’s real impact, we insist that the correct indication is mandatory for better results.

Background: To establish the puncture point for Combined Spinal Epidural (CSE) via conventional surface landmark assisted technique may be difficult in patients with obesity, degenerative spinal diseases and kyphoscoliosis, large prick numbers. the study to compares the success rate of placement of CSE via midline approach in first attempt of needle puncture in patients with difficult surface anatomy of lower back between surface landmark assisted group (SLG) and ultrasound assisted groups (USG).

Method: Randomized prospective study done with sample size (n= 50) each in the two groups SLG and USG. In USG vertebral space was scanned preoperatively and puncture point marked and in SLG puncture point was assessed by palpation of the surface landmarks. CSE was performed, efficacy of motor and sensory block was assessed. Primary outcome measured in the form of successful placement of CSE in first attempt of needle puncture.

Result: CSE was placed successfully in first attempt in 30 patients of SLG group and 46 patients of USG group with significant p value of 0.0003.Time taken for estabilishing surface landmark was 1.45±.47 minutes in USG group and 0.79±.34 minutes in SLG group with pvalue of < .001.

Conclusion: The use of ultrasound to mark the needle insertion point by assessing spinal anatomy for central neuraxial block increases the success rate of CSE in first attempt of needle insertion as compared to traditional surface land mark guided technique in patients with difficult surface anatomy of lower back. other significant outcomes still to be describe.

Recently a novel infusion pump strategy, mimicking manual intermittent bolus (MMIB) with increased flowrate, has been developed.This supposedly differs from other infusion pumps as its injectate is given as a bolus rather than infusion. This study aims to compare the effects of continuous infusion regimen with MMIB regimen in five different nerve blocks in fresh human cadavers.

The Institutional Review Board of Ethics of Penn State College of Medicine, USA approved this study for exemption for being a nonhuman. Bilateral ultrasound-guided peripheral nerve catheters (Pajunk® E-cath kit) were placed at five locations in two fresh cadavers.10ml of iodinated contrast material diluted in methylene blue dye were injected using either a Smith CADDTM or PainGuard™ pump. Within 20-min of injection the cadavers scanned using computer tomography (CT), then cadavers were taken to a laboratory and anatomical dissection of the cadavers was subsequently performed. The extent of methylene blue staining of muscles, nerves, fascial planes and tissues in each hemi-abdomen was photographed and documented. Descriptive statistics and unpaired t-tests were performed.

The MMIB infusion regimen provided greater spread for the four injections in both cadavers compared to the continuous regimen, (Figure 1 and 2) but these differences were not statistically significant. (Table 1a and 1b) There was significance (p<0.001 in the extent of dye spread between the male and female cadavers (Table 2a and 2b).

This preliminary study demonstrates a probable role of increase in flow rate of the infusion in future practice of continuous nerve blocks.

Dronabinol is an FDA-approved synthetic delta-9-tetrahydrocannabinol medication indicated for chemotherapy-induced nausea and vomiting and cachexia associated with AIDS. It can also be used off-label for various reasons. The primary aims of this institutional retrospective chart review study were to determine the prevalence of and reasons for inpatient dronabinol use in orthopedic surgical patients. We hypothesized that dronabinol is being prescribed off-label to surgical patients to manage perioperative pain.

After IRB approval, patients who received hospital-administered dronabinol at a large, urban, high-volume orthopedic surgery hospital were identified. Demographics, co-morbidities, preoperative cannabinoid use, surgery characteristics, and prescriber data were extracted from cases between December 2020 and 2022.

Inpatient dronabinol use increased between 2020 and 2022 but was prescribed in <0.5% of all surgical admissions (Figure 1). Preliminary review of 249 cases revealed that 91.2% (n=227) of patients used cannabis or cannabidiol prior to admission. Dronabinol was explicitly prescribed for pain management (9.6%, n=24), reduction of postoperative nausea and vomiting (3.6%, n=9), appetite stimulation (5.2%, n=13), sleep (3.2%, n=8) and prevention or mitigation of cannabis withdrawal symptoms (4.0%, n=10) during hospitalization. Physician assistants ordered 47.8% (n=119) of the inpatient prescriptions (Table 1).

Dronabinol was prescribed off-label for various perioperative issues, primarily to patients who reported preoperative cannabis use. Due to legal restrictions by the US federal government, patients cannot bring and use their cannabis products within a hospital setting, leaving them vulnerable to potential withdrawal symptoms or inadequately managed pain. Dronabinol may be a legal cannabinoid option for cannabis users during hospitalization.

Neuropathic pain is a major cause of disability worldwide. Managing peripheral neuropathic pain is a challenge demanding high doses of multiple analgesic agents together with interventional techniques. Peripheral nerve stimulation is an emerging field in minimal invasive techniques. A wire-like electrode is placed subcutaneously parallel to the nerves, involved with the area of pain distribution and connected with a small electrical device nearby, which delivers rapid electrical pulses bypassing the sensation of pain.

This study reports 2 cases, a 44 and a 51-year-old male, without comorbidities, who suffered from post-traumatic neuropathic pain in the forearm along the ulnar nerve. After physiotherapy protocols, several attempts for surgical decompression and therapeutic peripheral nerve blocks, the patients continued to present severe pain refractory to medication. In both patients, after locating the trajectory of ulnar nerve with ultrasounds, under locoregional anesthesia, we placed subcutaneously an eight -polar electrode connected with an external temporary neurostimulator and after a 7-days trial period of complete pain relief, we implanted a permanent neurostimulator subcutaneously.

Both patients were successfully treated as evidenced by 75% reduction in symptoms and discontinuation of medication. Both patients present with more than 75% reduction in pain after 1 year and 8 months follow-up respectively. None of the patients receives pain medication systematically anymore.

Placement of peripheral nerve stimulators could significantly change health care practice patterns and could substantially impact patient satisfaction and quality of life, providing a safe alternative to intractable neuropathic pain. However, more studies need to be conducted to prove their efficacy.

Intro: Von Willebrand disease (vWD) is the most common heritable bleeding disorder (1). However, there are limited reports regarding the safety of neuraxial anesthesia in the obstetric population and no definitive guidelines specifying recommended pretreatment (1).

Case Information: A 25 yo G2P1 @39 weeks is admitted to L&D. The patient is 2cm dilated with SROM. The patient states she has vWD, but did not know which type, was not under the care of a hematologist, and had an epidural with her first pregnancy and “it went fine.” Obstetrician was never told her patient had vWD. H/H 11.7/35.1, platelets 195. The anesthesiologist was hesitant about placing an epidural so a vWD panel was ordered. Lab results were not available until after the patient delivered. Von Willebrand activity 117, vWF 153, factor VIII 177 so overall the panel showed normal function.

Discussion: Epidural analgesia is usually contraindicated in vWD (2). Despite physiological increases in von Willebrand factor antigen, factor VIII, and activity levels near normal during the third trimester in Type 1 patients, epidural anesthesia is often withheld (2,3). When von Willebrand factor (VWF) and Factor VIII levels reach 80% or more it appears to be safe for epidural placement (4).

Conclusion: In patients with vWD who get pretreatment based on their type and severity can receive neuraxial anesthesia without adverse events (1). Knowing the type and severity for vWD is critical in being able to manage these patients for neuraxial anesthesia.

Patients with chronic low back pain (CLBP) are usually older adults and pain is difficult to manage. The aim of the study was to evaluate functional improvement after pain management using Oswestry disability assessment tool and to know the frequency of neuropathic pain using Douleur Neuropathic 4 (DN4) tool in patients with CLBP.

After approval from the Institutional ERC, all patients of both gender with chronic LBP presenting to pain clinic were included in this study, after written and informed consent. Data were obtained from patient’s medical records and interviews of patients using Douleur DN4 Neuropathic Questionnaires and Oswestry Low Back Pain Disability Questionnaire on the initial and follow-up visits till six months and recorded in a data collection form.

A total of eighty-seven patients completed the study and follow-up period to six months, of which 54 (62.1%) were Female. All patients had low back pain and the median duration of pain was 18 months. There was a statistically significant functional improvement (p <0.001) observed after pain management between initial visit and after six months using Oswestry disability index (ODI) (ODI value = 50.1 ± 14.7 vs 23.1 ± 14.1) and there is 53.89% reduction in pain. Using Douleur Neuropathic 4 (DN4) tool neuropathic pain was present in 35 (40.2%) patients with chronic low back pain.

Statistically significant functional improvement (p <0.001) was observed after pain management using the Oswestry disability index and the frequency of neuropathic pain using DN4 tool in patients with chronic low back pain was 40.2%.

This audit set out to investigate the outcomes of 35 block bay patients who had surgery purely under Regional Anaesthesia (RA), compared to 23 patients undergoing the same surgery with only general anaesthesia (GA) and no RA. AIMS Length of hospital stay, Same day discharge, Post Operative Pain Scores, Opioid requirements, Post Operative Nausea and Vomiting

A retrospective observational study was performed over 6 months on upper limb surgery done under only GA or Regional. Data from admission to discharge was collected. Excluded: Children Ring blocks Combined GA and RA

Most patients stayed overnight due to surgical reasons, however, overnight stay due to anaesthetic reasons was significantly less with RA vs GA (9% vs 17%). Average post op pain after GA was 3.2 vs 0 with RA, with GA patients requiring on average 9.9mg of morphine before leaving the recovery unit. 8.5% of GA patients developed PONV, compared to none after RA.

The incidence of same day discharge after upper limb orthopaedic surgery in UHW remains impressively high regardless of anaesthetic modality in patients who do not have surgical indications to stay overnight, however, incidence of overnight stay due to anaesthetic complications alone is significantly lower after RA alone compared to GA (9% vs 17%). Secondary outcomes measured showed a significant benefit to RA vs GA in all categories. It was found that a majority of ASA 3 patients received RA, thereby avoiding the risks of GA. The Block Bay hereby demonstrates a clear cost saving and service delivery improvement.

Hip fractures are some of the most frequent types of injuries among geriatric patients and they are mostly being managed surgically. Despite the development of different anesthesia techniques, this orthopedic procedure is still associated with increased morbidity and mortality rates. While General Anesthesia might be the preferred technique for patients on anticoagulants, Regional Anesthesia could be an alternative for elders for whom avoidance of airway instrumentation and reduced cardiopulmonary stress is mandatory. Recent medical literature has shown conflicting results regarding postoperative outcomes in geriatric hip fracture patients with different anesthesia techniques. The aim of this presentations is to illustrate the mechanisms of regional anesthesia and to assess its effectiveness when compared to general anesthesia for this patient category.

This review describes the advantages and disadvantages of both anesthetic techniques, as encountered in the recent medical literature.

The recent studies describing comparative efficacy of RA and GA showed no significant difference for 30 days mortality or length of stay. Also, there was no significant difference between the prevalence of postoperative delirium at 24h, 3 days and 7 days. Patients receiving spinal anesthesia required more analgesic prescriptions at 60 days compared to the GA group.

Although certain categories of geriatric hip fracture patients could certainly benefit from the usage of regional anesthesia, recent studies demonstrated no significant difference in postoperative outcomes. While definitive studies with larger sample size and adherence to a medical protocol are still in progress, the recommendations remain to adapt the anesthesia technique to the needs of the patient.

Inadequate postoperative pain control is associated with poor prognosis after surgery. Lung transplantation (LTX) patients are usually on mechanical ventilation with sedation in the immediate postoperative period, making it difficult to accurately measure postoperative pain. Instead, surrogate indices could be used to measure patient’s postoperative recovery, such as days alive and out of hospital (DAOH), which is a patient-centered outcome measure. This study aimed to evaluate DAOH as a predictor of prognosis after LTX.

We retrospectively included 246 patients who undergoing LTX at Severance Hospital, between 2012 and 2021. The optimal cut-off DAOH for prediction of postoperative overall survival was at 21.5 days using receiver operating characteristic analysis. We compared the preoperative, intraoperative and postoperative variables between LTX patients with DAOH>21.5 and those with DAOH<21.5.

Patients with DAOH<21.5 were older (60 vs. 56 yrs) and more patients with DOAH<21.5 were hospitalized (66% vs. 52%), admitted in the intensive care unit (55% vs. 35%) and on mechanical ventilation (48% vs. 27%) compared to those with a DAOH>21.5. More patients with DAOH> 21.5 were successfully weaned from extracorporeal membrane oxygenation during surgery (65% vs. 43%). The incidence of acute kidney injury, postoperative reoperation, pneumonia and sepsis were higher in patients with DAOH<21.5. Survival at 1 month and 1 year were significant higher in the DAOH>21.5 group compared to those with DAOH<21.5 (100% vs. 81% and 89% vs.47%).

Our findings suggest that the DAOH, which is a patient-centered outcome, is a useful surrogate marker for indicating patient’s postoperative recovery after LTX.

Genuine allergic reactions to amide local anaesthetics are extremely rare. When a 32 year old parturient with Local Anaesthetic (LA) Allergy presented to the Obstetric Anaesthetic Clinic, further investigation into the allergy was required. This lady, with a background of Charcot-Marie-Tooth disease, was told to avoid all LA’s after collapsing during a dental procedure as a child. During her first pregnancy in another hospital, she was told she would not receive any LA and had Entonox for labour analgesia and was given General Anaesthesia (GA) for a perineal tear repair. Following this experience she developed Post Traumatic Stress Disorder. She subsequently requested a caesarean under GA for this pregnancy. We referred her to the Allergy Clinic for a conclusive diagnosis.

The 38 week parturient was admitted to Labour Suite and under the advice of the Allergy Clinic, we performed subcutaneous challenge testing of Lidocaine and Levobupivacaine. We consented her for the testing, risk of anaphylaxis and early delivery of the baby including emergency caesarean section, and ensured all emergency drugs and equipment were available. We monitored Pulse, Blood Pressure, Peak Expiratory Flow Rate, and Cardiotocography. Increasing doses of Lidocaine were given incrementally at 20 minute intervals. Between each step, we observed the patient for signs of haemodynamic instability and local allergy. We waited one hour before testing the Levobupivacaine in the same way.

The lady did not develop any allergic reactions and can now have LA in future.

LA allergy testing at term pregnancy can safely identify true LA allergy.

Fibromyalgia is a disorder that affects many people around the world, with symptoms that include diffuse chronic musculoskeletal pain, fatigue, unrefreshing sleep, cognitive dysfunction, headaches, and morning stiffness. The pain associated with fibromyalgia can be difficult to manage. The aim of this revision is to analyze the potential of new therapeutic agents for the pain management of patients with fibromyalgia.

A systematic review was conducted to identify articles published after 2017, which evaluated the efficacy of novel therapeutic agents in pain management for fibromyalgia patients.

Pharmacological treatment options for fibromyalgia include cannabinoids and anti-nerve growth factor agents, which have shown effectiveness in reducing pain and improving sleep. Non-pharmacological interventions, such as non-invasive brain stimulation and mind-body therapies, have also been shown to aid in fibromyalgia pain management. Transcranial magnetic stimulation (TMS), a form of non-invasive brain stimulation, has been shown to reduce pain in patients with fibromyalgia. Mind-body therapies, on the other hand, have been shown to reduce stress and help patients cope with fibromyalgia.

Combining pharmacological and non-pharmacological interventions may provide the most effective treatment approach. Treatment plans need to be individualized, as each person can develop fibromyalgia for different reasons. While some people may respond well to a combination of medications and physical therapy, others may benefit more from physical therapy alone. There is still a need for more effective and targeted treatments for fibromyalgia-associated pain. Further research is needed to fully understand the mechanism of action, safety, and efficacy of these interventions in fibromyalgia patients.

Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system characterized by chronic inflammation with subsequent demyelination. Choosing the anesthetic technique for cesarean section in patients with MS can be challenging, especially in view of concern for disease aggravation when using neuraxial techniques. We report a safe anesthetic management of a woman with MS undergoing cesarean section with epidural anesthesia.

40-year-old woman with secondary progressive MS manifesting as left hemiparesis, proposed for elective cesarean section. In anesthesia consultation, the risks and benefits of neuraxial anesthesia were explained. After obtaining informed consent, under standard ASA monitoring, we performed an uneventful epidural anesthesia (L3-L4) with ropivacaine 0.75% 12ml (90mg) and sufentanil (10µg). For analgesia, paracetamol (1000mg), ketorolac (30mg) and epidural morphine (2mg) were administered.

Hemodynamic stability was observed throughout the procedure. The surgery was uneventful and the epidural catheter was removed in Postanesthesia Care Unit. Effective analgesia was achieved. The patient, discharged and sent home after 3 days, manifesting neurological deficits similar to the preoperative period. After 1.5 months in neurology consultation, superimposed neurological condition was observed, with no reports of relapse.

Currently, sufficient evidence for safe administration of epidural anesthesia is available in patients with MS. No correlation was found between epidural anesthesia and disease exacerbation. This has been theorized to be of less risk than spinal anesthesia due to the reduced concentration of local anesthetic in intrathecal space. With this case, we conclude that epidural anesthesia may be a safe option for cesarean delivery in women with MS.

Peripheral regional anesthesia has been integrated into most multimodal analgesia protocols for total knee arthroplasty which considered among the most painful surgeries with a huge potential for chronicization. The adductor canal block (ACB) has gained popularity. Similarly, the IPACK block has been described to provide analgesia of the posterior knee capsule. This study aimed to evaluate the analgesic efficacy of this block in patients undergoing primary PTG.

90 patients were randomized to receive either an IPACK, an anterior sciatic block, or a sham block (30 patients in each group + multimodal analgesia and a catheter in the KCA adductor canal). GROUP 1 KCA GROUP 2 KCA+BSA GROUP 3 KCA+IPACK The analgesic blocks were done under echo-guidance preoperatively respecting the safety rules, the dose administered was 20 cc of ropivacaine 0.25% was used. We were to assess posterior knee pain 6 hours after surgery. Other endpoints included quality of recovery after surgery, pain scores, opioid requirements (PCA morphine)(EPI info 7.2 analysis).

-groups were matched -A predominance of women (4F/1H). -average age: 68 +/-7 years -the average BMI =31.75 kg/m2 +/- 4. -70% of patients ASA2 ,20% ASA3. -The average duration of the intervention: 89 +/- 19 minutes. -Morphine consumption (PCA) significantly higher in group 1 (16mg) & group 2 (8mg) group 3 (4mg) - The groups were matched . -There was a correlation between the use of the ipack block and postoperative pain

In a multimodal analgesic protocol, the addition of IPACK block decreased pain scores and morphine consumption ,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long standing consequences, such as reduced functional capabilities and loss of work. Over recent years there has been an increase in awareness of the importance of early identification, aggressive pain management and adequate safety-netting for these patients. Poor management leads to increase rates of morbidity and mortality. Aim: Development of an evidence based, multidisciplinary chest injury pathway for the management of patients presenting with rib injuries in the Emergency Department

We used Plan Do study Act cycles as a framework for our quality improvement project. Patients' note presenting with torso trauma were reviewed from march to June 2021. Our five Specific, Measurable Actionable Realistic and Timely (SMART) measures were: analgesia on arrival, time to analgesia, fascial block performed, discharge leaflet given and compliance with the pathway.

Implementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. The use of the pathway by doctor and nurses was 63%.

This quality improvement project involved the development of a multidisciplinary pathway for patients presenting to the Emergency Department with rib fractures in order to drive a change from previous practice. The quality of care provided to patients attending with rib fractures showed improvement with increases in analgesia received, blocks performed, and discharge advice given.

Local anaesthesia (LA) nerve infusions are increasingly used in our institution for rib fracture analgesia; they provide not only excellent analgesia but reduce morbidity, mortality and improve economic outcomes [1]. Data from a local audit demonstrated 33% of rib fracture LA infusions were prematurely removed due to accidental disconnection. Currently there is no consensus on the optimum method of securing LA catheters in place [2]. Accordingly, we aimed to reduce rates of catheter disconnection through a benchtop experiment to determine the optimal LA catheter fixation method.

We used a porcine abdominal wall model (figure 1) to determine the force required to displace catheters secured using seven methods (table 1). We used our in-service wingless catheter-through-needle system (Pajunk), except when examining suturing strength, where a Vygon arterial line with suturing wings was used. The force required to displace the catheter by 1cm from the skin was measured. Each method was repeated 5 times. Data was analysed using parametric tests.

Catheters secured using Tegaderm and Dermabond (13.04 N, p=0.0004), Epifix and Dermabond (11.18 N, p=0.007) and Tegaderm and suturing (42.18 N, p=0.001) required significantly more force to displace than those using Tegaderm alone (5.94 N)(figure 2).

Tegaderm with suturing was the most effective method of catheter fixation, requiring a force several times that required to displace catheters secured using other means. However, Tegaderm and Dermabond provide effective fixation while also being both more cost-effective and patient/operator friendly. Consequently, we changed our department’s catheter fixation policy to advocate routine use of skin glue.

In high risk patients, pain arising from rib fractures can lead to pulmonary complications with associated morbidity, mortality and cost implications. Optimising pain relief is vital and regional analgesia (RA) is viewed as the gold standard. In a major trauma centre, referrals for analgesia in patients with chest wall trauma continue to rise (Figure 1), and where regional analgesia has traditionally been limited to the operating theatre complex, delays in performing RA for this at-risk group impact patient outcomes.

A multidisciplinary working party scoped opportunities for performance of RA for rib fractures in the emergency department (ED). Detailed stakeholder analysis identified numerous barriers to be overcome.

Barriers included: • Capacity required to train ED staff on catheter placement and management • Governance of non-anaesthetic staff performing catheter techniques • Concerns of potential drug errors with in situ catheters • Specialty prioritisation of patients with rib fractures • Reduced availability of anaesthesia providers during out of hour periods. An infographic of the resultant guideline highlights how key barriers were addressed by the working group (Figure 2).

Effective interdepartmental working can lead to service innovation and improvement. Minimising delays in performing RA will positively impact patients admitted to our centre with major chest trauma, and helps to embed RA within service provision.

Chest wall trauma is a notorious anaesthetic challenge and high opioid analgesia requirements, hypoventilation, hypostatic pneumonia and respiratory failure are common complications. Regional anaesthesia (RA) techniques have emerged as good adjuncts to reduce opioid consumption. In this study we describe the demographic and outcome data of patients that have received RA for analgesic management of chest wall trauma.

We retrospectively collected data from electronic health records on all patients with chest wall trauma who received RA techniques following acute pain team referral from October 2018 to August 2022.

We reviewed data from 187 patients. Mean age was 64.25 years, median fracture burden of 7 per patient, with 47 patients presenting with bilateral fractures and 88 having a flail segment (Table 1). Of these patients, 131 received an erector spinae plane (ESP) block and 43 had serratus anterior plane (SAP) block with median block duration of 4 days. Twenty-two patients required high flow nasal oxygen at 24h of admission and 149 required critical care admission with 43 needing invasive ventilation and a median length of stay of 5 days (Table 2). RA significantly reduced opioid consumption in 24 hours after procedure (20mg vs 14mg, p<0.01, Figure 1) and 168 patients survived to hospital discharge.

The patient cohort presented had a high burden of chest wall injury and need for critical care resources. Our analysis demonstrated reduction in opioid consumption following RA techniques. Given the potential deleterious effects of opioid analgesia, RA should be offered to patients with significant chest wall trauma.

Inferior vena cava and Aortic measurements and indices like IVC and Aorta diameter , collapsibility index, distensibility index etc are established parameters for intravascular volume assessment in adults. Literature in pediatric patients is scanty especially in the perioperative setting. This study was planned to evaluate the inter-observer reliability of ultrasound measurements of the IVC and Aortic diameters using the sub-xiphoid trans-abdominal long axis (SXTL) view in fasting pediatric patients, both during spontaneous and controlled ventilation.

After institutional ethics approval and informed consent 50 patients, aged 1 to 12 years, were assessed for intravascular volume indices during spontaneous ventilation and controlled ventilation by two blinded observers, one experienced in ultrasound and one trainee using the SXTL view.

The inter-observer reliability for SXTL view was assessed using intraclass correlation coefficient (ICC) and was found to be excellent to good. The ICC for the maximum IVC diameter (IVC max) during spontaneous ventilation was 0.879 (0.787-0.931), for minimum IVC diameter (IVC min) was 0.708 (0.485-0.834) and for maximum aorta diameter (Ao max) was 0.695(0.459-0.827). The ICC for IVC max during controlled ventilation was 0.866 (0.758-0.925), for IVC min was 0.851(0.735-0.915) and for Ao max was 0.866(0.765-0.924).

There was good inter-reliability for measuring the diameter of IVC and aorta during both spontaneous and controlled ventilation, using the SXTL view. After a short training session, a trainee can reliably measure the diameter of these vessels using this view.

Thoracic continuous spinal anaesthesia (T-CSA) is emerging as a sole anaesthetic for major abdominal surgeries due to its better perioperative outcomes. The present study is designed to evaluate block characteristics and outcomes in opioid-based (Bupivacaine with Fentanyl-group BF) versus opioid-free (Bupivacaine alone- group B), T-CSA for major abdominal surgeries in a doubled blinded randomized control trial.

Patients were randomized into B and BF groups. The outcomes measured were peri-operative rescue opioid requirement, opioid-related side effects, dose of bupivacaine required to achieve T4 level, pain scores, conversion to general anaesthesia, hemodynamic stability, patient and surgeon satisfactions, gut motility, length of hospital stays, in-hospital morbidity and mortality

A total of 50 patients underwent T-CSA technique, 25 in each group. The opioid based group performed significantly better compared to bupivacaine alone group with respect to decreased intrathecal bupivacaine requirement [induction (p=0.012) and maintenance (p=0.031)], post-operative rescue fentanyl requirement (p=0.018), pain scores at rest at 0, 18, 24 hours and patient satisfaction (p =0.032) at the cost of increased post-operative nausea and vomiting (PONV)

Opioid based T-CSA reduced postoperative rescue analgesia requirement, improved patient satisfaction and better postoperative analgesia with manageable PONV when compared with bupivacaine alone group. But both groups, provided equal surgical anaesthesia conditions. We did not observe single morbidity, re-exploration, re-admission and in hospital mortality in any of groups. However, more studies with the larger sample size and different optimal combinations of drugs are required to establish the role of CTSA in major abdominal surgery.

Regional anesthesia for minimal invasive cardiac surgery (MICS) gained interest as part of Enhanced Recovery After Cardiac Surgery (ERACS) protocols. At our institution, mitral valve surgery through port access (MVS-PA), aortic valve replacement via right anterior thoracotomy (AVR-RAT) and minimally invasive direct coronary artery bypass (MIDCAB) surgery are regularly performed MICS procedures. This study aims to investigate whether the addition of a single-shot SAPB to the standard institutional practice reduces NRS in MICS patients.

After obtaining consent, 80 MICS patients were randomized to receive either an additional SAPB after surgery (levobupivacaine 0.25%, dosed at 1.25 mL/kg) or IV piritramide as per protocol alone. The primary outcome is Numeric Rating Scale (NRS), 6 hours after extubation. Secondary outcome measure is total piritramide consumption in the ICU. A subgroup analysis per MICS procedure is performed.

In the SAPB group (n = 42), MIDCAB patients had a significant NRS reduction of nearly 2 points (difference: 1.71; 95% CI: 0.412 - 2.945; p = 0.023). In the SAPB group, postoperative opioid consumption was reduced by 2.3 mg; however, the 95% CI spans 0 (-3.948 – 7.344; p = 0.048).

In patients undergoing a MIDCAB procedure, our study demonstrates adequate pain relief when a superficial SAPB is performed. Reported pain scores at 6h and piritramide consumption were lower during ICU stay. Future research needs to investigate the added value of the SAPB in the recovery of MICS patients.

Epidural analgesia is accepted as the gold standard for pain relief in labour. Maternal obesity is increasingly common and is known to be associated with morbidity. The American Society of Anesthesiologists suggests early placement of an epidural in women with obesity to reduce the need for general anaesthesia if an emergent procedure becomes necessary. We wanted to review the use of epidural analgesia and how commonly it was used for emergent caesarean section.

We conducted a retrospective review from 2019 to 2022. This was done by searching the notes for women with a BMI >40 kg.m-2. The search identified age, BMI, use of epidural analgesia and type of anaesthetic.

We identified a total of 780 women with an average BMI of 42.7 kg.m-2. 166 women (21.2%) had an epidural placed for pain relief in labour. The mode of delivery following epidural analgesia is shown in the attached chart.

Our results show a low uptake of epidural analgesia in this group which is similar to the rate in the non-obese population. The most common mode of delivery following epidural analgesia was spontaneous vaginal delivery. Only 29% of epidurals were used for category 1 and 2 LSCS. This questions the recommendation about an early epidural in this group. We either need to advocate more strongly for epidurals to improve their usage in this group or stop giving this advice and accept that only in a small minority of cases will an epidural prevent use of a GA in an emergent procedure.

Total hip replacement (THA) is recommended with multimodal analgesia, with peripheral nerve blockade being popular due to its opioid sparing properties1–4. PENG (Pericapsular Nerve Group) block, which has shown analgesic efficacy in THA, preserves sensory supply to the posterior hip capsule5–8. this study compares the analgesic efficacy of PENG block with PENG and PS sciatic nerve block, which blocks the sensory supply to the posterior capsule7,9,10

After informed written consent, 30 ASA (American Society of Anaesthesiologist’s) classification I and II patients scheduled for elective THA were randomised into two groups A and B. After induction of general anaesthesia, Group A received US guided PENG block whereas Group B received combined PENG and PS sciatic nerve block. Post-operatively patients were administered intravenous(IV) fentanyl via. Patient Controlled Analgesia(PCA) pump. Analgesia was compared to PCA fentanyl consumption at 24 and 48 hours, as well as the numerical rating scale (NRS) score at different time intervals

Group B had reduced 24 hour (88.3±2mcg vs 69.3±28.5mcg) and 48 hour (158.7±26.4 mcg vs 118.1±24.2 mcg) IV fentanyl intake. In groups A and B, the time for rescue analgesia was 124.51 minutes (min) and 171.2 minutes (min), respectively. Patients in both groups were mobilised 24 hours after surgery, with a median worst NRS score of 4.

Combined PENG and PS sciatic nerve block reduces perioperative fentanyl consumption and pain scores in THA patients compared to PENG block.

Various approaches to quadratus lumborum block (QLB) have been found to be an effective analgesic modality after cesarean delivery (CD). However, the evidence for the superiority of any individual approach is still elusive. Therefore, we conducted this network meta-analysis to compare and rank the different injection sites for QLB for pain-related outcomes after CD.

PubMed, EMBASE, SCOPUS, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials evaluating the role of any approach of QLB with placebo/no block for post-CD pain. The primary outcome was parenteral consumption of morphine milligram equivalents in 24 postoperative hours. The secondary endpoints were early pain scores (4-6 hours), late pain scores (24 hours), adverse effects, and block-related complications. We used surface under cumulative ranking (SUCRA) probabilities to order approaches. The analysis was performed using Bayesian statistics (random-effects model).

Thirteen trials enrolling 890 patients were included. The SUCRA probability for parenteral morphine equivalent consumption 24 hours was highest (87%) for the lateral approach, followed by the posterior and anterior approaches. The probability of reducing pain scores at all intervals was highest with the anterior approach. The anterior approach also ranked high for PONV reduction, the only consistent reported side effect.

The anterior approach QLB had a superior probability for most patient-centric outcomes for patients undergoing CD. The findings should be confirmed through large RCTs.

Multimodal regimens, are the mainstay of postoperative analgesia. This study compares analgesic efficacy of, Programmed Intermittent Bolus (PIB) and Continuous. Infusion (CI) pumps, ultrasound guided Adductor Canal Block (ACB) with catheter, for unilateral knee arthroplasty.

Ethical and Clinical Trial Registry approved, included patients were randomized into two groups, intraoperatively, either general, or spinal anaesthesia, pericapsular infiltration, postoperatively, ACB, received 0.2% Ropivacaine. Group-I, PIB pump 10 milliliters every 3 hours, Group-II, 6 milliliters/ hour as CI. Additionally, both groups received Patient Controlled Analgesia (PCA) with 5 milliliters boluses and 30 minutes lockout interval. The Numerical Rating scale (NRS) score, plasma concentration of 0.2% Ropivacaine, adjunct analgesics, quadricep strength by straight leg rising (SLRT) test, Medical Research Council (MRC) scale for motor power, monitored at 0, 1, 4, 8, 24, 48, 72 hours, and Likert scale for patient satisfaction, measured at 72 hours. Sample size calculation, a difference in the NRS of two points to be clinically meaningful. Power of 0.80 and Standard Deviation(SD) of 2 points, it took at least seventeen patients from each group to detect a 2-point difference in NRS pain levels.

PIB group,patients experienced better analgesia only in the first 24 hours and motor power, in the first and fourth hour after recovery. Ropivacaine plasma concentration, at regular intervals were independent to the pain scores with movement and rest. Rescue analgesia was inconclusive in both groups.

PIB option, proved better analgesia in the post operative period.

The incidence of hypotension in pregnant women with COVID-19 undergoing regional anesthesia remains a controversial. The aim of this study is to investigate the incidence of hypotension during spinal anesthesia in pregnant women infected with COVID-19, as well as to identify associated risk factors.

This retrospective study compared COVID-19-positive parturients who underwent cesarean section with spinal anesthesia between January 2021 and June 2022 (group COVID-19) with a control group of patients who underwent the same procedure between January 2017 and December 2021 and were statistically matched for age, weight, and height with the group COVID-19.

The COVID-19 group received low-dose bupivacaine anesthesia and showed comparable levels of anesthesia and blood pressure reduction to the control group. However, they required more colloid usage. A positive correlation was noted in the COVID-19 group between heart rate and hospital stay duration (p=0.000, Spearman’s rho= 0.422). Further analysis based on initial heart rate revealed that group H (100 or higher) had lower Apgar scores at 1 minute, longer hospital stays, and more severe COVID-19 symptoms. Moreover, in group H, there was a positive correlation between heart rate and the lowest systolic blood pressure after spinal anesthesia (p=0.012, Spearman’s rho=0.528).

COVID-19 pregnant women have a higher risk of hypotension during cesarean section under spinal anesthesia compared to non-COVID-19. Given the close association between preoperative heart rate and the extent of hypotension in COVID-19 pregnant women undergoing spinal anesthesia, vigilant monitoring of vital sign by anesthesiologists is crucial during the perioperative period.

The aim of our study is to compare medial and lateral approaches of the costoclavicular BPB which became procedure of choice for upper limb anaesthesia. We hypothesized costoclavicular block through medial approach would result in shorter performance time owing to favourable anatomy.

After IEC approval, 60 patients participated, 30 in each group. In group M, needle was advanced in a medial to lateral direction, whereas in Group L, needle was advanced in lateral to medial direction. 20ml of 0.5% bupivacaine were used in both groups. The primary outcome assessed was performance time. The secondary outcomes preliminarily analysed were Imaging time, Needling time, Total Anaesthesia time, Anaesthesia success, Performer difficulty score. Further subgroup analysis concerning other outcomes are ongoing. As two patients were switched over to Group L due to unfavourable sono-anatomy, we ran statistical analysis by modified Intention to treat analysis and as per protocol analysis. We summarise results from mITT analysis.

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

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

Neuraxial anaesthesia is a common effective anaesthesia technique. Traditional palpation is the usual technique for detecting the vertebral interspace, but it has limitations. A novel hand-held ultrasound guidance device, Accuro, has been used recently. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of ultrasound-guided neuraxial anaesthesia compared to traditional palpation in patients undergoing neuraxial anaesthesia.

Randomized controlled trials were sought in six databases for a systematic review and meta-analysis. With a 95% confidence interval, a random-effects model calculated Risk Ratio or Mean Difference. Cochrane Risk of Bias tool assessed bias. Five RCTs were included, a total of 369 patients. This review was registered with PROSPERO with the identifying code CRD42023416937.

Five studies with a total of 369 patients met our criteria. The risk of bias in four studies was low and there was some concern in one study. First insertion success rate showed a favorable risk ratio for the Accuro compared to Palpation, the risk ratio was 1.44 [95% CI 1.01 – 2.05, P= 0.05], Accuro caused a significant reduction in needle skin passes[MD -0.63; 95% CI (-1.05; -0.21); p<0.01], while failing to demonstrate a significant reduction in needle redirection [MD -1.31 (95% CI: [-2.71; 0.11], p = 0.07)]. Procedure time was significantly shorter in palpation [MD 127.82; 95% CI (8.68; -– 246.97); p=0.04]

Accuro is effective in reducing the number of trials needed to perform a successful insertion for spinal anesthesia and the results of our meta-analysis support the use of Accuro in clinical practice.

The Perioperative Pain Service (POPS) at Hospital for Special Surgery (HSS) is a multidisciplinary team that manages acute and complex pain in orthopedic surgical patients. Under POPS, the chronic/complex pain service (CPS) team has a structured approach to preoperatively identify patients with chronic opioid use, substance use disorder or other complex pain issues, and tailors perioperative pain management plans to optimize outcomes. The aim of this study was to identify overall CPS utilization and case characteristics in a single, high-volume orthopedic specialty hospital.

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

Between January 2022 and May 2023, 7,228 surgeries were captured in the POPS registry of which 1,709 (24%) involved CPS. Arthroplasty and spine represented 47% and 29% of these cases, respectively (Figure 1). Overall, 1,048 (61%) had an in-person, preoperative pain consultation. Patient-controlled analgesia was administered in 73% of cases; perineural catheters were placed in 23 cases (2%), of which 15 (65%) were after a total knee replacement. Post-discharge POPS consults were required in 1% of CPS cases.

CPS manages patients’ post-surgical pain through a multi-pronged approach. While most patients were appropriately identified preoperatively and referred to CPS by the surgical team, there is room for improvement. The low percentage of post-discharge POPS follow-ups reflects appropriate discharge planning with the patients’ surgical, pain and primary care providers.

Pregnant people with obesity class 3 are thought to be at higher risk of adverse respiratory-events. There is little information in the literature on the incidence and severity of obesity-related postpartum respiratory depression. Our institution's current standard of practice is to consider maintaining patients with BMI>50 who have received long-acting neuraxial opioids following cesarean delivery(CD) in the Labour and Delivery Unit for respiratory monitoring. This represents a significant workload for the system. This study aimed to determine the incidence of respiratory complications in this subset of patients.

We reviewed medical records of patients with BMI>40 who underwent CD and received long-acting neuraxial opioids between January 2015-December 2022. Patients were divided into three groups according to their BMI: 40-49, 50-59, and >60. Clinically significant respiratory-events (see the definition in Table-1) within the first 24 hours post-CD were compared.

Demographics, patient characteristics, comorbidities, and respiratory events are presented in Table-1. No severe respiratory events were observed in any of the groups from 497 patients (Graph-1). Three moderate respiratory-events were observed, one in each group. Thirteen, 9 and 5 mild respiratory-events were observed in BMI 40-49, 50-59, and >60groups, respectively.

Our results suggest that there is no association between BMI and severe respiratory-events after CD under neuraxial anesthesia and the use of long-acting neuraxial opioids. Extended admission to a high-acuity setting may not be necessary for the majority of these patients. In addition to BMI, the presence of patient comorbidities and physician assessment may prove valuable in determining the necessity for admission.

Periarticular infiltration (PAI) and adductor canal block (ACB) have become popular modes of pain management after total knee arthroplasty. The purpose of our study is to evaluate the efficacy of ACB combined with PAI in comparison with PAI alone for pain control and patient satisfaction in patients undergoing primary total knee arthroplasty.

This study is a prospective observational study that is conducted at a single university hospital in Belgium. Thirty six patients operated on for primary knee arthroplasty in the enhanced recovery pathway were included. Patients who received the ACB combined with PAI (n=18) were compared with those who received the PAI alone (n=18). The primary outcome is visual analog scale score (VAS) at recovery room to patient mobilization at 24 hours after surgery, whereas the secondary outcomes include satisfaction, opioid consumption, length of hospital stay and complications. The study is approved by the Ethics committee of CHU Charleroi, Belgium (CCB: B325201942327, on 27/11/2019).

In the ACB+PAI, the VAS are better than the group of PAI alone at 12 hours after surgery and at the mobilization (24 hours after surgery) (p-value=0,011; 0,001). The morphine consumption is clearly reduced during this period in the group ACB+PAI (p-value=0,006; 0,009). Patient satisfaction is also better when BCA is added (p-value=0,008). The length of hospital stay is less long in the ACB+PAI group (p-value=0,007). No significant difference in complications.

The adductor canal block provides better control of analgesia , with more satisfied patients compared to the PAI alone group.

Consistency in needle tip positioning within interfascial planes while performing infiltrative blocks under ultrasound guidance may be difficult. Such planes go beyond the physical limits of common ultrasound machines. Aim of this pilot study was to understand if injection pressure monitoring at the needle tip can help to immediately and consistently identify an interfascial plane needle tip placement.

We performed 4 ultrasound-guided TAP blocks on cadaver using a modified conventional peripheral nerve block needle. The sensing needle contains a miniaturized pressure sensor floating 1 mm from the needle tip, connected to a measuring unit via an optical fibre. Injection-pressure measured at the needle tip was continuously recorded, while the needle was advanced toward the target and 0.9% saline was continuously injected via an electronic pump.

A recognizable, recurrent three-peaks injection pressure pattern was identified (Fig 1.), while advancing the needle through the abdominal wall, the pressure peaks being identified with the needle to fasciae contact. In four different blocks, a total of 12 peaks and 12 troughs were identified. The mean injection pressure (95%CI) of the peaks varied substantially from the mean injection pressure of the troughs, from 119.55 kPa (95% CI 87.3 to 151 kPa) to 30.99 kPa (95% CI 12.5 to 47.5 kPa), respectively. The peaks (troughs) arose from reproducible pressure curves and were related to the needle tip encountering the muscle fasciae.

The identified injection pressure pattern, together with ultrasound image, may help in determine real-time the needle tip position, while performing a TAP block

Retrospective and clinical studies on patient undergoing cancer surgery suggested the perioperative use of local anesthetic drugs might improve the outcome. Previous publications indicated that lidocaine reduced cancer metastasis by inhibiting the tyrosine kinase enzyme Src. However, there is no data investigating the impact of lidocaine in non-epithelial cancer cells. The aim of this investigation was to explore in vitro the impact of lidocaine on cancer of mesenchymal origin. For this purpose, osteosarcoma and Ewing sarcoma cell lines were used.

Adhesion assays were performed by treating the cells for 48h compared to verteporfin in 6 well plates. Migration was assessed by the Boyden chamber migration during 48h. DMSO was used as control. Wound healing assays was performed during 48h and assessed with the MRI wound healing tool in Image J in cells being treated either with or without TNF-α. Src activity was evaluated by western blotting.

Adhesion (Fig. 1), migration (Fig. 2) and wound healing (Fig. 3) were not influenced by the presence of lidocaine with or without stimulation with TNF- α. The addition of methylnaltrexone did not modify the results. Src activity was similar to the control and not increased by the addition of TNF-α.

Contrary to what has been found with cancer originating from epithelial cells, lidocaine does not prevent adhesion and migration of osteosarcoma and Ewing sarcoma cells from mesenchymal origin. Further investigations, including Src pathway activation, would be required to identify mechanistic differences between cells of epithelial or mesenchymal origin towards anti-metastatic properties of local anesthetics.

This meta-analysis aims to evaluate the impact of Erector Spinae Plane (ESP) block on opioid consumption within the first 48 hours postoperatively in patients undergoing open hepatectomy and its effects on postoperative nausea and vomiting (PONV).

PubMed, EMBASE, and Cochrane were searched for randomized controlled trials (RCTs) comparing the ESP block to IV analgesia for open hepatectomy in adults. We assessed incidence of PONV and opioid consumption in the postoperative period. Statistical analyses were performed using RevMan 5.4. Risk of bias was appraised using the RoB-2 tool. (PROSPERO - CRD42023415616).

We analyzed 3 RCTs involving 150 patients, of whom 50% underwent ESP block. No significant differences were found in opioid consumption (Figure 1) or incidence of PONV (Figure 2) between the groups.

According to the results of our meta-analysis, the performance of the ESP block in patients undergoing open hepatectomy does not result in a significant difference in opioid consumption during the initial 48 hours following the surgical procedure. This may be due to the high heterogeneity between the findings reported by the accessed RCTs. Additionally, there was no difference in the incidence of PONV. These results suggest that further studies with less heterogeneous protocols are needed.

This prospective double-blind randomized study aimed at evaluating the analgesic efficacy of ultrasonography-guided transversus abdominis plane (TAP) block when adding dexmedetomidine to the local anesthetic solution in patients undergoing unilateral elective inguinal hernia repair under general anesthesia.

Fifty-eight patients were allocated to TAP block with either a solution of 25ml ropivacaine 0.5% and 2ml N/S 0.9% (group R) or a solution of 25ml ropivacaine 0.5% and 2ml dexmedetomidine 0.5 mcg/kg (group RD). The primary end point was pain score during movement 24 hours postoperatively as assessed with the numeric rating scale (NRS). Secondary endpoints included pain scores during rest and during movement at several time points postoperatively, intraoperative remifentanil consumption, morphine administration in the Post Anesthesia Care Unit (PACU) and 24-hour postoperative morphine consumption administered via a patient-controlled analgesia device (PCA). Six and twelve months postoperatively, the occurrence of chronic pain was assessed by phone interview.

There was not significant difference demonstrated between the two groups as to the primary endpoint. However, the RD group demonstrated lower intraoperative remifentanil consumption (p<0.001), lower PACU morphine requirement (p=0.04), lower PCA morphine requirement (p=0.01) and lower NRS scores 3 hours postoperatively both at rest and during movement (p=0.02 and p=0.034) as compared to the R group. Additionally, the incidence of chronic pain at 6 months was significantly lower in the RD group compared to the R group (p=0.025).

Dexmedetomidine added to the local anesthetic mixture during TAP block performance seems to affect aspects of acute and chronic postoperative pain after inguinal hernia repair.

Lung hydatid cyst surgery causes considerable postoperative pain, and it can lead to postoperative pulmonary problems particularly in children . The erector spinae plane (ESP) block is a recently described , is simple to perform, and numerous studies have established the analgesic efficacy of ESP block in a variety of therapeutic settings. To compare the analgesic efficacies of erector spinae plane (ESP) block and spinal analgesia (SA) in lung hydatid cyct (LHC) of peadiatric surgery

eighty patients undergoing LHC, divided into two groups : group SA (had morphine spinal analgesia at a dose 3 micogramme/kg) and group ESP (patients had an ultrasound-guided ESP block at the end of surgery with 0.3 ml/kg Ropivacaine). The primary outcome was to compare pain scores at rest 24 h postoperatively between the 2 groups. Secondary outcomes included post operative FLACC scores for 48 h, procedural time, use of rescue medication, adverse events, and parental satisfaction

Patients with ESP block had a better FLACC score than those with SA but no statistical difference at a specific time. Cumulative Paracetamol consumption was higher in the ESP block group (p=0.047). The incidence of overall adverse events in the SA group was higher than in the ESP block group (p=0.045).

Erector spinae plane block may be inferior to SA for analgesia following LHC, but it could have tolerable analgesia and a better side effect profile than SA. Therefore, it could be an alternative to SA or thoracic epidural analgesia as a component of multimodal analgesia in children population.

The Erector Spinae Plane block (ESPB) is an increasingly used to provide analgesia for surgeries involving the chest wall, rib fractures and even cancer pain. Although several meta-analyses that demonstrated the effectiveness of this block, its mechanism of action is still unclear. Anatomical studies on this ESPB injectate spread have found inconsistent results. This systematic review was conducted to summarize the current knowledge about the injectate spread following ESPB.

Pubmed, Scopus and EMBASE were searched. All studies that examined the injectate spread after a thoracic ESPB involving the use of either dissection or imaging were included. The primary outcome was the presence of injectate spread in the various anatomical planes.

This review included 29 studies involving 113 cadaveric and 79 live subjects. The proportion of subjects with injectate spread in the erector spinae plane(ESP), intercostal space(ICS), epidural space(ES) and paravertebral space(PVS) was 1(95%CI: 0.97-1), 0.51(CI:0.38-0.64), 0.38(CI:0.28-0.5) and 0.57(0.49-0.64) respectively. The mean spread of injectate in the ESP, ICS, ES and PVS were 9.1(CI:5.1-13.2), 4.7(CI:2.0-9.3), 3.1(CI 0.1-3.6) and 3.5(CI: 0-7.3. Compared to cadavers, a larger proportion of patients had injectate spread in the ICS.

Based on this study, the likely mechanism of action of the ESPB is via its spread into the intercostal, paravertebral and epidural compartments. While this correlates with current studies showing superiority of ESPB over placebo/control, it also raises the possibility that the clinical effect of ESPB is likely to be unpredictable.

In the mammalian brain, the ventrolateral periaqueductal gray (vlPAG) and its neighboring dorsal raphe (DR) nucleus regulate analgesia and anxiety. The vlPAG GABA+ and DR GABA+ neurons display opposite roles in feeding, the specific function of these GABA+ neurons in pain regulation remains unknown. Opioids act on the opioid receptors expressed on vlPAG GABA+ neurons to inhibit GABA release, which in turn exerts anti-nociceptive effects. Although the analgesic potency of morphine indicates the distinct functions of the vlPAG and DR in pain modulation, the involvement of DR GABA+ neurons in opioid anti-nociception is still obscure. We aim to provide new insights into the modulation of pain and anxiety by specific midbrain GABAergic subpopulations, which may provide a basis for cell type-targeted or subregion-targeted therapies for pain management.

We combined cell-type specific chemogenetic and optogenetic approaches to dissect the function of GABA+ neurons within the vlPAG and DR in pain processing and emotional responses.

The co-activation of vlPAG-DR GABA+ neurons induced hypersensitivity to mechanical stimulation and anxiety-like behavior, while the inhibition of vlPAG-DR GABA+ neurons led to anti-nociception and anti-anxiety effects on mice with inflammatory pain. Moreover, we found the opposite effects of separately manipulating vlPAG GABA+ and DR GABA+ neurons on the nociceptive responses.

The activation and inhibition of vlPAG-DR GABA+ neurons bidirectionally regulate nociception and anxiety-like behaviors. We also found that vlPAG GABA+ and DR GABA+ neurons play different roles in modulating the sensitivity to mechanical stimuli in both naïve and inflammatory pain mice.

Pain management is crucial to decrease postoperative adverse events after septorhinoplasty surgery. Although the beneficial effects of infraorbital and infratrochlear nerve block for nasal surgeries have been studied, it's effect on opioid consumption has not been evaluated. Our aim was to investigate primarily the effect of infraorbital and infratrochlear block on remifentanil consumption hence the postoperative nausea/vomiting related to opioid consumption and need for rescue analgesia.

In this prospective, randomised controlled study, 62 patients undergoing elective septorhinoplasty surgery were randomised in to two groups: Control group (without nerve blockade) and Block group (bilateral ultrasound guided infraorbital block and infratrochlear block). BIS monitorization was utilised for all patients in both groups for standardization.The scores of Richmond agitation sedation(RASS), Numerical rating scale(NRS), Boezaart bleeding and also nausea, vomiting, remifentanil consumption and the duration of the surgery were recorded.

NRS score, remifentanil consumption and nausea were statisticaly lower (p<0.001) in Block group, while the patients in Control group were observed drowsy according to RASS score. Rescue analgesia was statistically high in Control group (p<0.001).

Ultrasound guided bilateral infraorbital block and infratrochlear nerve block can be considered in patients undergoing septorhinoplasty surgery, due to it's reducing effect on perioperative remifentanil consumption hence side effects of opioid consumption and postoperative pain.

Breast cancer is the most common cancer among women and one of the most important causes of death. Chronic pain develops in 50% of patients undergoing breast surgery. Regional anesthesia, decreased opioid requirements, PONV incidence, pulmonary complications, and length of stay in the PACU in these patients. Among the regional blocks, pectoral block type II stands out because it has a low risk of complications and easy applicability because the block is performed with a single injection under the guidance of ultrasonography.

70 patients with ASA II, aged 18-75, who were scheduled for mastectomy surgery, were included in the study. After randomization, an anesthesiology resident performed a PECS II block with AI-integrated USG or conventional USG (Group AI-USG and Group USG).

The two groups were homogeneously distributed in terms of demographic data. The time took for the anesthesia resident to perform the block was found to be shorter in the USG group. Intraoperative bradycardia was observed more frequently in the AI-USG group. At the same time, the rate of tachycardia in the PACU unit was lower in this group than in the USG group. VAS scores in the AI-USG group at PACU, postoperative 24. hours were 1 point lower than in the USG group; it was statistically significant. Postoperative Tramadol and nonsteroidal anti-inflammatory drug (NSAID) consumption PCA were lower in the AI-USG group.

Finally, we found that AI integrated USG technologies created by developing technology help block area imaging and block performance for beginners, although it's not statistically significant.

Neuroaxial techniques (NT) are commonly used for pain relief during labor. Many modalities have been introduced, each with advantages and disadvantages. The choice of the ideal approach is debatable and could be linked to various factors. We examined the factors associated with the choice of NT among a sample of parturients in Bissaya Barreto Maternity.

This is a retrospective, observational study of all patients (n=598) who had caesarean section (c-section) during 2022. Data were obtained from anonymous clinical records. Data collected included anesthetic approach technique, urgency of the c-section, previous presence of active labor, BMI of the parturient and APGAR score of the newborn. A chi squared (Q) analysis and adjusted residuals (AR) were used to reveal the association between variables.

A total of 598 c-sections were done: 556 (93%) with NT and 42 (7%) under general anesthesia (GA). There was no association between the choice of NT and the BMI of the parturient (Q 26,35;p 0,15) or APGAR score (Q 42,11;p 0,11). In the absence of labor there were higher than expected counts of combined anesthesia (AR 3,9; p<0,01) and lower epidurals (AR -5,7;p<0,01). If spontaneous or induced labor, epidural was chosen in higher counts than expected (AR 3,0 and 3,1 respectively). Emergent c-sections were positively associated with GA (AR 7,7;p<0,01).

GA was positively associated with emergent c-section. Epidural was negatively associated with elective c-sections and the absence of labor which was positively associated with combined anesthesia. BMI and APGAR were not related to the choice of anesthesia.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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