The use of central regional anesthesia is traditionally regarded as contraindicated in patients with severe aortic stenosis (AS) due to the risk of hypotension, decreased coronary perfusion, and acute myocardial ischemia. However, there is no high-level literature evidence in support of this recommendation. Since cardiovascular monitoring systems, diagnostics, pharmacology, and clinical practice patterns have improved, we polled anesthesiology practitioners to gauge their opinion on whether spinal anesthesia should remain contraindicated in patients with moderate-to-severe AS.

We surveyed the anesthesiology community of NYSORA to assess practitioners' perception of whether or not spinal anesthesia is contraindicated in patients with moderate-to-severe AS (the definition according to the 2014 AHA/ACC guidelines for the severity of AS).

A total of 130.000 NYSORA community members were polled. Of these, 82% comprised anesthesiology practitioners. A total of 1,400 (1.1%) community members posted a reply, Figure 1. Most respondents (68%) opined that spinal anesthesia is contraindicated in patients with moderate-to-severe AS.

Our poll results suggest that anesthesia practitioners continue to consider spinal anesthesia as contraindicated in patients with moderate-to-severe AS, although neuraxial anesthesia may be associated with better outcomes (e.g., in patients having joint replacement surgery). In view of the advances in monitoring and possible advantages of spinal anesthesia in specific populations, we believe that its safety in patients with AS should be formally evaluated.

Modified radical mastectomy is treatment of choice in patients having carcinoma breast. Covid era made us to change our practices towards regional anesthesia to prevent aerosol spread. Literature showed the maximum distance between duramater and spinal cord is at mid thoracic level, but very few studies are there to conduct modified radical mastectomies under segmental spinal anesthesia. So we also decided to conduct our cases under segmental spinal anesthesia during covid era to prevent aerosol transmission through general anesthesia.

This study was done at a tertiary care center after approval by the local ethical and research committee. We have taken 78 patients aged 20 to 70 years with ASA physical status 1-3 scheduled for modified radical mastectomies with axillary dissection from April 2020 to November 2022. Under aseptic precautions after local infiltration with 2ml 2% xylocaine adrenaline solution, subarachnoid block was performed at T5-T6, T6-T7 Level with 27 G Quincke Babcock needle. We used midline approach in all the patients with a 45° tilt of the needle using Richa,s angle . Once free flow of CSF was ascertained,1.5 ml isobaric levobupivacaine with 5 mcg Dexmedetomidine was given.

patients tolerated surgery well.9% percent patient had one episode of hypotension and 6 % patients had bradycardia, which was taken care of. Paresthesia was found during needle insertion in 4% patients, but none of the patient had neurological damage.

Segmental spinal anesthesia is a safe alternative of general anesthesia in cases of carcinoma breast undergoing modified radical mastectomy, in expert hands.

Pneumorrhachis is a rare complication of epidural analgesia and is most often asymptomatic. It can cause permanent deficit and differential diagnosis can be challenging, so clinicians should be aware of this entity.

A 74 year old woman was admitted to elective total knee replacement surgery. A L3/L4 spinal block using a paramedian approach was achieved after 2 attempts with a 25G quincke needle. An epidural catheter was placed with loss of resistance (LOR) to saline through L3/L4 intervertebral place, by single attempt. The procedure was uneventful and the sensitive and motor block reversed in the PACU. Before the transference to the ward, an epidural DIB was initiated with 0,1% ropivacaine, 5 mL/h. 4 hours later, the anesthesiologist was called for a bilateral sensitive and motor block up to T10 and urinary retention. After neurologist’s assessment and DIB clamping, an MRI revealed intradural and extradural air collections, in locations compatible with the deficits presented. The patient was transferred to the hyperbaric medicine center with oxygen inhalation via a non-rebreather mask. Upon arrival, the deficits had completely reversed and it was decided to do 12 hours of normobaric oxygen therapy. Patient was discharged by 6th post-operative day and no other complications was observed.

Pneumorrachis after an epidural technique with LOR to saline is rare. Our most plausible hypothesis was that air could have been entrapped in the DIB. It usually gets reabsorbed spontaneously1. Nonoperative treatment includes hyperbaric oxygen therapy, which can lead to reabsorption of trapped air.

When the risks of approaching a difficult airway are high, regional anesthesia often becomes a wiser option. In order to avoid general anesthesia it becomes necessary to implement strategies that maximize the effectiveness of regional techniques, including optimizing patient cooperation and favoring regional techniques whose duration can be extended to meet the needs of prolonged surgery.

Patient: 88-year-old female, with diabetes, hypertension, degenerative osteoarticular disease, dementia, and previous maxillectomy with ATM arthrodesis. Procedure: Hip arthroplasty due to hip frature Anesthetic plan: A dexmedetomidine infusion was started 2 hours before coming to the operating room and was maintained throughout the procedure (0,1-0,4mcg/kg/h). A continuous spinal catheter (25G) was placed in L3/4, through an intrathecal Sprout needle (21G) - IntraLong (r) 21G/25G PAJUNK. An initial bolus of 2.5mg levobupivacaine 0,5% + 2.5mcg sufentanil was administered. The procedure lasted 2 hours and an additional dose of 1mg levobupivacaine 0,1% was given. The catheter was removed at the end of the procedure.

The patient remained in RASS -2, on spontaneous ventilation, without the need for additional oxygen supply and was hemodynamically stable throughout the procedure. The postoperative course was uneventful.

In this case, avoiding the airway was highly desirable, but delirium could compromise patient cooperation during regional anesthesia. Sedation was necessary and dexmedetomidine was chosen because of its beneficial effect on delirium and respiratory stability. Continuous spinal anesthesia was chosen for its effectiveness in surgical anesthesia and due to the unpredictability of the duration of the procedure.

The Tsui test, also known as the epidural electrical stimulation test (EEST) is a simple, safe, and reliable method for objective assessment of correct thoracic epidural catheter placement with a sensitivity and specificity of 80-100% to 91.6-100%. Test uses low-amplitude electrical current applied to an epidural catheter and conducted through a column of saline to elicit a motor response

We present a 61-year-old female, undergoing the repair of recurrent ventral incisional and parastomal hernia. After obtaining written consent the patient was positioned siting on the bed. The epidural was placed at T9 level. A spring-loaded catheter was advanced without any resistance into the epidural space and Tsui test was performed to define the tip of the catheter. A positive motor response was detected at 3mA at patient’s upper abdomen. Several seconds after initiation of nerve stimulation patient became bradycardic. Heart rate decreased from 61 to 38 bpm and blood pressure decreased from 153/78 to 92/38. Pacer spikes were noted on a monitor preceding each QRS complex. The patient remained bradycardic and did not recover immediately after the stoppage of electrical stimulation. Glycopyrrolate 0.2 mg was administered which improved the patient’s symptoms. The patient tolerated the test dose and epidural throughout the course of her stay. The patient was discharged home without any complications on post op day 3rd.

We suggest that immediate availability of rescue medications like glycopyrrolate, atropine, along with vasopressors in patients undergoing epidural catheter placement using Tsui test as additional safety measure should be followed routinely.

This case reports a rare thoracic epidural induced priapism and evidences the importance of prompt recognition and treatment to preserve erectile function.

A 44-year-old, male, ASA II, underwent exploratory laparotomy and sigmoidectomy. Prior to general anesthesia induction, a thoracic epidural catheter was inserted at T10-T11. An initial bolus of 7 mL ropivacaine 0.2% was administered and sensory block was distributed from T6 level. No intercurrences were reported during the procedure and the patient was transferred to PACU with an epidural infusion of ropivacaine 0.15 % at 5 mL/h. An erection was observed 13 hours postoperative. The epidural infusion was discontinued and Urology was consulted. Blood was aspirated from the corpora cavernosa to induce detumescence, which was unsuccessful. An injection of diluted epinephrine was then administered. No more erections were reported after discontinuation of the epidural infusion. The patient was referred to urology consultation and discharged.

In our case, we hypothesize that epidural was responsible for the low-flow priapism, considering the absence of direct trauma or hematological disease, uncorrelation of the surgical site with erectile physiology and priapism reversal following discontinuation of the epidural infusion. Priapism has been previously reported as a complication of epidural injection with opioids or in combination with local anaesthesia1-3.

This is a rare complication with unknown incidence and poorly understood pathophysiology. Nonwithstanding, prompt identification is vital to prevent permanent damage. Otherwise, it may lead to emergency intervention as described here. Awareness must be raised regarding epidural-induced priapism to ensure early identification.

Epidural infusions provide good-quality analgesia after thoracic, abdominal and lower limb surgery and are commonly encountered in the post-operative patient in the high dependency unit. Management of epidural catheters and infusions are core skills for anaesthetic trainees, however recently the number of non-anaesthetic trainees working in critical care has increased. Exposure to epidural anaesthesia amongst this group is variable. Out of hours, in the absence of the pain team, the responsibility for management of the malfunctioning epidural may fall to a non-anaesthetic trainee. The aim of this project was to assess and improve knowledge of epidural infusions amongst non-anaesthetic trainees rotating through critical care.

A 10-question multiple-choice questionnaire (MCQ) on epidural infusions was distributed amongst non-anaesthetic trainees rotating through critical care in our institution. An educational session was provided for a subset of this group after which they re-completed the MCQ. Pre- and post-education session scores were compared.

15 non-anaesthetic trainees completed the MCQ, achieving an average score of 57% (range 40-70%). Eight trainees attended the education session. The mean post-education MCQ score improved to 95% (range 90-100%). The question most commonly answered incorrectly was related to calculating the length of catheter in the epidural space from the depth to loss of resistance and depth at skin. Key safety-related questions related to infusion rates, management of motor block and anti-coagulation were answered correctly by all participants following the education session.

Familiarity with epidural infusions is mixed amongst non-anaesthetic trainees. A short educational session improves knowledge and familiarity amongst this group.

Ankylosing spondylitis (AS) is a chronic, progressive inflammatory disease that affects the spine and sacroiliac joints. Disease spectrum may range from mild rigidity to bone fusion of the spine. Inevitably, neuraxial blockade may be technically difficult or impossible to achieve due to closed interspinous spaces and loss of flexibility. Tracheal intubation may also be difficult because of the involvement of cervical spine and temporomandibular joint. Cardiopulmonary complications are frequently present, demanding a careful pre-operative evaluation.

A 69-year-old woman with a long history of AS presented for hip replacement surgery. The patient had a bamboo spine with accentuated thoracolumbar kyphosis and no mobility of cervical spine, which was fixed in a flexed posture. After positioning in right lateral decubitus, spinal anesthesia was achieved after 3 attempts, at L3-L4 interspace, paramedian approach, with a 25G Quincke needle. 9 mg of isobaric bupivacaine 0,5% and 2 mcg of sufentanyl were administered. Ultrasound guided femoral nerve block and lateral femoral cutaneous nerve block were previously successfully performed.

The sensory and motor blocks were adequate, and the patient remained hemodynamically stable thorough surgery.

AS presents significant challenges to the anesthesiologist, thus requiring a careful anesthetic planning. Regarding regional anesthesia, the major concerns are the difficulty of the technique, increased risk of complications and the unpredictable sensory and motor spread of the neural blockade. If general anesthesia is necessary, awake fiber optic intubation should be considered, and cardiopulmonary pathology held in consideration.

Ropivacaïne or 1-propyl-2', 6'-pipecoloxylidide, is a non-racemic chiral amino-amide similar to Bupivacaïne in terms of structure. It differs from it by the substitution on its amine group of another group butyl replaced by a propyl group. It is considered as a pure S-levorotatory enantiomer of the molecule. Unlike Bupivacaïne, which is a racemic equimolecular mixture of the two enantiomers. The objective of our study is to integrate and to generalize the use of Ropivacaïne in spinal anesthesia.

Descriptive prospective interventional comparative clinical study, for 120 adult patients were recruited and randomly divided into two groups (Ropivacaïne group and Bupivacaïne Group), 60 patients in each arm who were admitted to the operating room to undergo scheduled or urgent surgery requiring. The data collected are mainly the demographic and anthropometric characteristics. and perioperative hemodynamic parameters, namely: blood pressure (BP), heart rate (HR), incidence of acute toxicities cardiovascular. The data collected was analyzed by SPSS "20" software and Excel 2013 software.

120 patients were included in our study, hemodynamic stability with the use of Ropivacaïne, with low cardiovascular toxicity compared to the Bupivacaïne group satisfaction in the Ropivacaïne group.

The anesthetic drug type Ropivacaïne is promising for spinal anesthesia. The results found in our study are globally similar to those reported in the literature, which can conclude on the contribution of Ropivacaïne compared to Bupivacaïne in terms of efficacy and tolerance, with early ambulation. Finally, it can be used as a possible alternative to Bupivacaïne in loco regional anesthesia.

Use of Ultrasonography (USG) in performing regional blocks is well established. Many anaesthesiologist are still reluctant to use USG to identify landmarks in patients with distorted spinal anatomy. USG is as an effective tool and helps anaesthesiologist to identify various landmark in patients suffering with any kind of spinal deformity. Here we present a case of 52 years old patient posted for Cytoscopy and TURP with a huge right sided lumbar hernia containing right kidney and bowel loops, causing spinal deformity. This case report details the problems faced by anaesthesiologist in positioning the patient, difficulty in administering spinal anaesthesia and how difficult spinal anaesthesia was overcome with use of Ultrasound as guide for identifying various anatomical landmarks.

This is a case report along with review of literature.

Experienced anaesthesiologist can visualize neuraxial structures with satisfactory clarity using USG. A preprocedural scan allows to preview the spinal anatomy, identify midline, locate a given intervertebral level, accurately predict the depth to space, and determine the optimal site and trajectory for needle insertion.

USG guided neuraxial anesthesia is noninvasive, safe, can be quickly performed, does not involve exposure to radiation, provides real-time images, and is free from adverse effects. USG guided neuraxial anesthesia is a rapidly developing alternative to traditional landmark-based techniques. In experienced hand USG can be an important tool in providing CNB in specific patients. As US technology continues to improve and as skills become more widely available, use of US for CNB may become the standard of care in future.

Transient Neurological Symptoms (TNS) are characterized by transient moderate to severe pain at the lower extremities, appearing 2-24h post block reversal. Risk factors include the use of lidocaine/mepivacaine, positioning in lithotomy and knee surgery. Aetiology is unclear, but thought to be related to the neurotoxic effects of local anaesthetics, needle trauma or ischemia. The treatment is symptomatic and prognosis is favourable.

A 75-year-old male, ASA III, insulin dependent diabetes was scheduled for an elective inguinal hernia repair. He had a recent lumbar discectomy with good recovery. The airway evaluation revealed short and wide neck and a 3 cm mouth opening, thus spinal anaesthesia was preferred. Spinal block was performed under sedation (3 attempts), at L3-L4 level, with 10mg isobaric bupivacaine 0.5% and 2 mcg sufentanyl.

After blockade reversal, a marked clinical picture characterized by lower limbs (LL) paraesthesia, predominantly in the feet. Pain radiated to the left LL and did not follow radicular territory, associated with LL strength deficit bilaterally (Grade 3 and hypoesthesia throughout the left LL, up to T10). MRI excluded acute conditions and neurosurgery/neurology evaluation pointed to aa anaesthesia-related condition. He initiated therapy with dexamethasone and reinitiated ambulatory pregabalin with progressive symptomatic improvement with complete resolution after 10 days.

When symptoms surge after central neuraxial block, serious causes such as spinal hematoma, abscess and cauda equina syndrome must be excluded before considering TNS. Despite the risks, regional techniques are safe and useful alternatives to general anaesthesia as in this predicted difficult airway case report.

Radical robotic prostatectomy is increasingly popular. Our aim was to evaluate the analgesic requirements post radical robotic prostatectomy performed under general anaesthesia with caudal block.

An audit was conducted between April 2008 and October 2018. 896 patients who underwent radical robotic prostatectomy received a standard general anaesthetic (paracetamol 1 gm, ondansetron 4mg, dexamethasone 6.6mg fentanyl 100microgram, propofol, desflurane and atracurium infusion) with caudal analgesia containing 40ml 0.25% bupivacaine, 150 micrograms clonidine and 100 micrograms fentanyl. Regular paracetamol was prescribed post-operatively, oral morphine 20mg 3 hourly, cyclizine and ondansetron were available on an ‘as required’ basis. Visual analogue scale (VAS) score, analgesic consumption and the incidence of side effects were recorded at 30 min and 24 hours post-surgery.

24 (3%) patients required additional intraoperative morphine. Only 136 (15%)) had a VAS greater than 3/10 post-operatively with the highest being 8/10 in 8 patients. All patients received regular paracetamol. 148 (17%) required oral morphine within the first 24 hours post-operatively. Only 68 (8%) patients required intravenous morphine (10-20mg) in recovery. There were no major side effects associated with the caudal block. 112 (12.5%) suffered post-operative nausea and vomiting. Mean inpatient stay was 29.4hrs.

A general anaesthetic with caudal block provides excellent intra- and post-operative analgesia with minimal side effects. This has important implications in terms of patient satisfaction, minimising side effects and facilitating early hospital discharge.

Large retrospective studies have clearly established the outcome benefits of spinal anesthesia over general anesthesia in patients having hip fracture surgery. However, recent data from a prospective, randomized study (Neuman et al. NEJM 2021) challenged the benefits of spinal anesthesia with regard to survival advantages, the ability to walk independently, and postoperative dementia. We polled the anesthesia community to investigate whether spinal or general anesthesia is perceived as a preferable choice for patients with hip fractures.

We solicited a reply to the following question on the NYSORA community page: “If you were a patient with a hip fracture and if expertise in both spinal and general anesthesia were available, which anesthetic technique would you choose for your own hip fracture surgery?” The reply options are listed in Figure 1.

Of 130.000 NYSORA community members, 82% comprised anesthesiology professionals. Of these, 4% of the community members posted a reply (5.200 respondents), Figure 1. Most respondents (72%) chose spinal anesthesia over general anesthesia for their own hip fracture repair.

Although the recent outcome study on spinal versus general anesthesia (Neuman et al., NEJM, 2021) challenged the benefits of spinal anesthesia in patients with hip fracture, our poll suggests that anesthesia practitioners would prefer spinal over general anesthesia for their own hip fracture surgery. These results could have been skewed due to the likely larger prevalence of regional anesthesiologists in the NYSORA community.

NRFit connectors are 20% smaller and 3mm longer than standard Luer connectors [1]. Does switching to NRFit connectors from Luer connectors of the same manufacturer increase the perceived resistance to flow during aspiration and injection when performing spinal block? This study compares the flow resistance to water between: (a) Pajunk® NRFit versus Pajunk® Luer of the Sprotte® 24G x 90mm spinal needles. (b) Vygon® NRFit versus Vygon® Luer of the Whitacre® 25G x 90mm spinal needles.

Thirty ward nurses who had never used these needles volunteered to test these spinal needles in a simulated practice. Each needle was primed with water and then attached to a 5 ml syringe containing 3 ml water. Using the same hand, each nurse was asked to aspirate 1ml from a glass filled with 10 ml water and then inject 3 ml under the water in the same glass. Unlimited attempts were permitted until they could determine the needle with the lowest resistance or if they felt that there was no difference in resistance between the two needles from the same manufacturer.

Figure 1: Perceived Lower Resistance to Injection using Pajunk® NRFit and Pajunk® Leur of the Sprotte® 24G x 90mm Spinal Needles (n=30) Figure 2: Perceived Lower Resistance to Aspiration using Vygon® NRFit and Vygon® Leur of the Whitacre® 25G x 90mm Spinal Needles (n=30)

Within the measure parameters, volunteers perceived a lower resistance to injection using the NRFit connectors. In contrast, they perceived lower resistance to aspiration using the leur connectors.

To compare the efficacy and tolerability of 0.5%Levobupivacaine and 0.75%Ropivacaine in patients undergoing lower abdominal surgery

56 patients, ASA grade 1 and 2 were randomised to receive an epidural injection of study drug 17 ml 0.5% Levobupivacaine in group L or 17 ml of 0.75%Ropivacaine in group R.

The mean time for onset of sensory block(faster), maximum dermatome reached (higher) in R group but the time taken to attain maximum sensory level in two groups is similar. The two-segment regression and the duration for regression of sensory block to T10 was slower in group R compared to group L. Total duration of analgesia in R group was 301.96 min, whereas in L group it was 319.09 min (p value0.57). The time for complete reversal of sensory block was 345.54 min in R group versus 418.93 min in L group. (p value<0.05) The onset of motor block, regression of motor block and duration of motor block were comparable in both the groups. The grade of motor block was significantly different in both groups (p value<0.05). The time taken to attain the maximum motor blockade was 40.18 min vs 17.86 min in group L ( p value 0.04). The mean duration of motor block in R group was 146.25 min and in L group was 160.71 min (p value>0.05).

Both 0.5%Levobupivacaine and 0.75%Ropivacaine produced effective and well tolerated epidural anaesthesia for patients undergoing lower abdominal surgery.

Continuous spinal anaesthesia (CSA) is a seldom used anaesthetic technique. Advantages of CSA over other neuraxial anesthesia techniques include its ability to maintain anaesthesia for prolonged periods by administering low, incremental and titrated doses of local anaesthetic, reducing haemodynamic instability while providing a fast and dense block.

A 65-year-old male patient, ASA IV, was admitted for closed reduction and osteosynthesis of a pertrochanteric femoral fracture. Relevant medical history included severe aortic stenosis, coronary artery disease, cardiac pacemaker, chronic kidney disease undergoing hemodialysis, insulin-treated diabetes, hypertension, and obstructive sleep apnea on CPAP. Furthermore, the patient had previously undergone a maxillectomy and subsequent reconstruction, resulting in a severely restricted mouth opening. Considering the patients comorbidities, predicted difficult airway and surgical procedure, CSA was elected as the anaesthetic technique.

Standard ASA monitoring with invasive blood pressure evaluation was used, and a preemptive strategy formulated for potential difficult airway management. An epidural needle was used to detect the subarachnoid space (SAS) in the L4-L5 interspace. A catheter was left 3cm inside the SAS and 5mg (1ml) of 0,5% levobupivacaine and 2,5mcg (0,5ml) of sufentanil were injected intrathecally as the initial loading dose. Subsequent doses of levobupivacaine were titrated as needed. At the end of surgery the catheter was removed and a femoral block with 15ml of 0.25% levobupivacaine performed. The procedure was uneventful, hemodynamic stability was maintained and airway manipulation avoided.

CSA is an effective and adequate technique for frail patients who benefit from avoiding general anesthesia and demand a more rigorous hemodynamic control.

Continuous spinal anesthesia (CSA) is particularly useful in lower limbs surgery in patients with cardiovascular and respiratory comorbidities.

A 74-year-old male, BMI 27 Kg/m2, ASA IV status, was scheduled for urgent supragenicular amputation due to critical ischemia of the left lower limb. The patient had a history of type II diabetes mellitus, hypertension, heart failure (ejection fraction of 34%) NYHA lll, atrial fibrillation, recent pulmonary embolism, and COPD. The patient was under anticoagulants, antiarrhythmics, anti-hypertensives, bronchodilators, and oral hypoglycemic agents. Laboratory analysis showed Hb 10.6 g/dL, no coagulation abnormalities (LMWH was stopped for 24 hours) and normal renal function. The patient was alert, eupneic without supplemental oxygen and hemodynamically stable. The patient was proposed for CSA with standard ASA and invasive blood pressure monitoring

A Tuohy needle was placed at L3/L4 level and the catheter was inserted 4 cm into the subarachnoid space. One milliliter of bupivacaine 0.5% was administered, achieving a T8 block within 10 minutes; a repeated dose of 0.5 ml was given 45 minutes later. The surgery proceeded without complications. Hemodynamic stability was maintained without the need for vasopressor support. At the end of surgery, 100mcg of morphine was given through the catheter and the intrathecal catheter was removed.

In this case, CSA was an effective and safe option for a high-risk surgical patient. The advantage (over single-shot spinal anesthesia) to adjust the level of anesthesia and prolong its duration, with lower doses of local anesthetics, reduced the risk of complications such as hypotension and respiratory depression.

Hypertrophic Cardiomyopathy (HCM) is characterized by marked hypertrophy of the myocardium and it’s frequently accompanied by dynamic left ventricular outflow tract (LVOT) obstruction. Although patients with HCM may not demonstrate LVOT obstruction under basal conditions, dynamic obstruction can develop with the administration of anesthesia. Classically, LVOT obstruction has been considered a relative contraindication to neuraxial anesthesia.

We report a case of a successful continuous subarachnoid block (CSB) in a 66-year-old, ASA III, female patient with HCM proposed for urgent right ankle fracture surgery. Pre-operative transthoracic echocardiogram showed asymmetrical left ventricular hypertrophy and a peak LVOT gradient of 13mmHg at rest and 67mmHg with Valsalva maneuvre. After informed consent and placement of invasive arterial pressure monitoring, premedication with 1mg of midazolam was conducted.An ultrasound-guided popliteal sciatic nerve block with 20mL of 0,375% ropivacaine was performed on the right leg followed by placement of a subarachnoid catheter at the L3-L4 level. A total of 2,5mg of 0,5% levobupivacaine and 0,003mg of sufentanyl were injected into the subarachnoid space.The surgery was uneventful and the patient remained hemodynamically stable. No complications were reported and the patient was later discharged home.

In our case the execution of a CSB allowed for titration of local anesthetic dosage, which permitted hemodynamic stability while giving optimal anesthetic effect. We also believe the use of premedication as well as peripheral nerve blockade for perioperative analgesia contributed to the overall success of this case.

Anesthesiologists must understand the physiopathology of this disease, as LVOT obstruction can cause life-threatening hemodynamic instability.

Combined spinal-epidural (CSE) is a neuraxial technique where injection of local anaesthetic into the subarachnoid space and placement of an epidural catheter is performed in the same procedure.

Case 1 is a 69-year-old female who underwent total knee arthroplasty. CSE was performed using a needle-through-needle technique with the B.Braun Espocan®. 18G Tuohy needle was inserted at L3/L4 in the midline in sitting position and advanced until loss of resistance to saline obtained. 27G spinal needle was inserted through Tuohy needle up to the maximal protrusion length, however no CSF was obtained. Epidural catheter was inserted and epidural anaesthesia initiated with 15mls 0.5% bupivacaine. Case 2 is a 63-year-old male who underwent total hip arthroplasty. CSE was performed with the same technique. Intrathecal component was not given as CSF was not flowing freely. Epidural catheter was inserted and epidural anaesthesia initiated with 18mls 0.5% bupivacaine.

Both patients underwent total knee and hip arthroplasty uneventfully under epidural anaesthesia in an operative time of 4 and 5 hours respectively.

Failure of the spinal component in CSE in these cases are likely due to deviation from midline resulting in the spinal needle missing the subarachnoid space laterally or in the dural-arachnoid side wall. In both cases, after removal of the spinal needle, epidural anaesthesia was administered. Alternative rescue techniques would include threading the epidural catheter and performing subarachnoid block using a separate spinal needle at a different interspace; or repeating the CSE technique at the same or different interspace with direction of needle medially.

With the SARS-CoV-2 pandemic, regional anesthesia techniques gained more impact because of the need to avoid airway manipulation. To assure a fast recovery and ambulation, prilocaine was used more frequently due to its fast onset and lower duration of action.

We describe a case of methemoglobinemia in a patient submitted to a uterine aspiration after an abortion during the first trimester.

The patient weighted 50kg and had a medical history of ulcerative colitis medicated with sulfasalazine. She was anesthetized with spinal anesthesia with 60mg of hyperbaric prilocaine. After 17 minutes of the spinal technique the oxygen saturation dropped from 98-99% to 90% and a bluish discoloration on her lips was detected. With the assumption of a case of methemoglobinemia associated with prilocaine administration, methylene blue 1mg/kg was administered (50mg). The procedure was terminated, and she was admitted for surveillance. The case resolved with no complications.

Methemoglobinemia is a rare complication associated with prilocaine. Normally higher doses are associated with the development of this syndrome. Sulfasalazine and other drugs administration may enhance the probability of the occurrence of methemoglobinemia. Methylene blue is an effective antidote for methemoglobinemia due to its own oxidizing properties.

Short-acting intrathecal local anaesthetics, such as prilocaine, have advantages for ambulatory day-case surgery due to rapid onset and offset of anaesthesia, rapid recovery of protective reflexes, mobility and micturition. Intrathecal prilocaine for day-case unicompartmental knee replacement (UKR) has been introduced at an orthopaedic hospital in the UK. The study aims are: 1. To assess feasibility of an ambulatory spinal service for elective UKR 2. To introduce prilocaine for day-case UKR

Stage 1 was a retrospective review of 29 UKRs in 2020 recording time from anaesthesia to surgery end to demonstrate feasibility of prilocaine use. Stage 2 recommended using heavy prilocaine 20% with fentanyl. Data collected for UKR cases between Jan – May 2023 included anaesthetic dose, time from anaesthesia to surgery end, post-operative pain scores, analgesic requirements, length of stay and patient satisfaction.

Stage 1 found that mean procedure time was 72mins. Stage 2 found that 80% were discharged within 24h, 0% had urinary retention, pain scores were between 2-10/10, they all required oral opiate analgesia, time to mobilisation was poorly documented, patient satisfaction was between 4 and 5 out of 5.

UKR can successfully be achieved as a day-case procedure with intrathecal prilocaine. To facilitate this patients should be first on the theatre list and receive pre-operative education regarding physiotherapy and post-operative analgesic requirements. Good analgesia is required with regular paracetamol, NSAIDs if not contraindicated and opiates. A guideline for all multidisciplinary teams, including physiotherapy, pharmacy and the ward nurses will further support same day discharge.

Inguinal hernia repair is one of the most commonly performed elective surgical procedures. Total extraperitoneal(TEP) which is the most preferred one among laoparoscopic methods, is usually performed under general anesthesia (GA). However, there are reports showing TEP has been performed under regional anesthesia. We would like to share our experience on this matter.

A 40 year-old male patient presented to general surgery service wtih pain and swelling in the right inguinal region and was scheduled for TEP inguinal hernia repair. Since he had elevated liver enzymes, we preferred spinal anesthesia (SA). SA was performed at L3/4 spinal level with 15 mg of plain 0.5% Bupivacaine and 20 mcg Fentanyl. Sedation was provided with IV midazolam 2mg, fentanyl 50 mcg and titrated propofol infusion. After the sensorial block reached level T4,procedure started. Insufflation pressure of 12 mmHg and supine position maintained during the surgery. The patient was hemodinamically stable and had no complaints throughout the surgery which lasted 90 mins. After the procedure he did not need painkillers for the first 4 hours, was discharged on the 1st postoperative day.

SA is not meant to replace GA for TEP but can be used as an alternative for patients who have contraindications for GA. The purpose of this report is to demonstrate that laparoscopic hernia repair can safely and effectively be performed under SA.

TEP inguinal hernia repair can be safely performed under SA, and SA was associated with less postoperative pain, better recovery, and better patient satisfaction.

Coffin-Siris syndrome (CSS) is a rare genetic disorder, with less than 250 molecularly confirmed cases worldwide. It is characterized by growth restriction, developmental delay, craniofacial malformations, and a range of heart, gastrointestinal, genitourinary and nervous system abnormalities. These abnormalities may present an anaesthetic challenge mainly due to difficult airway management, respiratory complications and poor patient cooperation. The available literature on CSS anaesthetic approach consists of 10 case reports, with only one describing a regional anaesthesia technique.

A 14-year-old female patient with CSS was scheduled for bilateral proximal tibial hemiepiphysiodesis. Preoperative evaluation was significant for developmental delay, obstructive sleep apnoea, IgA deficiency with several respiratory infections over the last year and hypertrophic cardiomyopathy. A history of doubtful delayed emergence from general anaesthesia, despite recovery of spontaneous ventilation, was present in past procedures. Physical examination revealed obesity, a short neck and macroglossia. A deep sedation was accomplished intravenously with propofol and fentanyl, and maintained with sevoflurane 1,5%, ensuring spontaneous ventilation through a laryngeal mask airway. An L3-L4 epidural block was performed with ropivacaine 0,5%. ASA standard monitoring and bispectral index were applied, and multimodal analgesia was ensured.

Hemiepiphysiodesis was successfully performed under the proposed anaesthetic technique, combining neuraxial anaesthesia and sedation. The perioperative period was uneventful.

CSS patients can be challenging for the anaesthesiologist due to the syndrome’s malformation spectrum, cardiac structural disease, respiratory complications and lack of reassuring literature. Neuraxial anaesthesia may be a successful and safe approach for CSS patients in selected procedures.

Posterior Reversible Encephalopathy Syndrome (PRES) is characterized by neurological symptoms and white matter edema on neuroimaging studies. While many etiologies and risk factors have been described, its pathophysiology remains unclear.

A 50-year-old woman was admitted with an abnormal vaginal bleeding due to a large uterine fibroid causing severe anemia (Hemoglobin: 2g/dL). She was otherwise healthy. Over the next ten days, she received a total of five packed red blood cell units. Twelve days after admission, she was submitted to an uneventful hysterectomy under general anesthesia and epidural analgesia. Postoperative analgesia was maintained with ropivacaine 0,1% through an epidural drug infusion balloon at 5cc/h which was removed 48 hours after the procedure. Three days after surgery, she developed headaches and vomiting followed by altered mental status, focal neurological deficits and seizures. She was treated with antiepileptic medication, supportive care and transferred to an ICU. Neuroimaging ruled out a stroke and revealed typical findings of PRES. Within a week the neurological deficits fully reversed and the patient was discharged from the hospital.

Although it is associated with hypertension, PRES is also linked to polytransfusion and central nerve blocks.

A wide array of etiologies and risk factors are associated with PRES and a literature review is required to better understand this syndrome in the perioperative period, including its relationship with central nerve blocks.

Post-spinal shivering is a common side effect of spinal anesthesia, particularly in elderly patients. This prospective randomized double-blind controlled study has the purpose to explore the effectiveness and safety of low dose intravenous clonidine, propofol and clonidine plus propofol for prophylaxis of shivering in elderly undergoing lower abdominal surgery under spinal anesthesia

80 patients (ASA I-III, age>65 years) scheduled for lower abdominal surgery under spinal anesthesia participated in the study. They were randomized to four groups, each of them with 20 patients, to receive 50µg clonidine (group C), 0,25 mg/kg propofol (group P), 50µg clonidine and 0,25 mg/kg propofol (group KP) and saline (group S). Drugs were administered after subarachnoid anesthesia with hyperbaric bupivacaine was performed. During surgery we recorded every 10’ the incidence of shivering and its severity using Bedside Shivering Assessment Scale as primary endpoints. Secondary endpoints included the incidence of sedation and nausea/vomiting and the evaluation of hemodynamics during surgery. Student’s t test was used for statistical interpretation considering p<0,05 as significant.

The incidence of shivering was significantly lower in groups CP (p<0,001), P (p<0,05), C(p<0,005) compared to placebo. Among the groups that received prophylactic medication, group CP showed an advantage documented by statistically relevant decrease of shivering incidence (p<0,01) compared to the other two groups . The incidence of sedation, the occurrence of nausea/vomiting and hemodynamic parameters registered similar values in all study groups.

The combination of clonidine and propofol provide synergistic effects and is effective for controlling post-spinal anesthesia shivering in elderly .

Ultrasound is a boon to anesthesiologists and pain physicians. Ultrasound facilitates anesthesiologists to recognize the mid line, preview the anatomy of spine, and properly identify the inter-vertebral space, especially in obesity, kyphoscoliosis and ankylosing spondylitis. Ultrasound guided subarachnoid block is a less utilized technique which reduces the number of needle passes, which in turn reduces the trauma, bloody tap and spinal hematoma. A 70yr male patient with right sided femur neck fracture was posted for hemiarthroplasty with bipolar prosthesis. Patient was a known case of bronchial asthma since 15 years on salbutamol metered dose inhaler. He was diagnosed with ankylosing spondylitis 40 years back. His X ray lumbosacral spine demonstrated syndesmophytes, enthesitis of interspinal ligaments and ankylosis of bilateral sacro iliac joints. Airway examination showed severely restricted neck extension.

After patient came to operation theater, monitors were connected. After starting intravenous fluid, patient was made to sit for spinal block. With all aseptic precautions, real time ultrasound guided subarachnoid injection was performed using 25 G quincke spinal needle in L3-L4 intervertebral space. We injected 15 mg of 0.5 % bupivacaine heavy.

Real time ultrasound guidance facilitated us to identify the proper inter-vertebral space and perform the technique with less hassle and speed. We got the cerebro spinal fluid flow in second attempt. Patient was comfortable throughout the procedure and surgery was uneventful.

Real time ultrasound guidance for central neuraxial blockade is advantageous over anatomical landmark technique in difficult spine anatomy patients and need to be taught and utilized in future.

Laparoscopy is a procedure requiring total muscular relaxation , traditionally performed under GA Regional anaesthesia provides total analgesia and muscle relaxation with complete preservetion of consciousness and rapid postoperative recovery. Spinal and combined spinal-epidural blocks have been used for laparoscopic general surgery in patients with relevant medical pathologies including coexisting pulmonary disease This study shows the feasability of all types of laparoscopic surgery under CSE , on awake patients

655 ASA I to III patients between 30 and 80 years old scheduled for different laparoscopic surgery ( cholecystectomy , appendicectomy , colectomy , sigmoidectomy , inguinal hernia , prostatectomy and hysterectomy ) were included in this protocol after informed consent After monitoring preloading and light sedation , with the patient in left lateral decubitus epidural space was identified by the lost of resistance to air technique between L1-L2 A 27G spinal needle was introduced in the subarachnoid space and 20 mg Bupivacaine + 7,5 µg Sufentanil + 4 mg Dexamethasone in a total volume of 5 ml were injected Patients were placed in the Trendelemburg position until sensitif block level at T2 Maximum intraperitoneal pressure didn't exceed 12 mm Hg

70 patients ( 10,68%) experienced shoulder pain after pneumoperitoneum successfully treated with 0,5 mg iv alfentanil 1 patient required conversion to GA Duration of procedures ranged between 25 and 180 mins

RA affords excellent muscle relaxation, total per and postoperative pain relief , rapid discharge . Different studies showed a better outcome in frail and obese patients compared to GA

Literature on thoracic spinal anaesthesia (TSA) for breast surgery is scarce. The present series explored block characteristics and outcomes in the patient undergoing Modified Radical Mastectomy (MRM) under TSA in female patients with ASA I-III physical status.

20 patients underwent unilateral MRM. TSA was given with 0.75% isobaric ropivacaine (1ml), fentanyl (25 g) and dexmedetomidine (10 g) at T4-T5 space. All patients received IM glycopyrrolate and IV ondansetron pre-operatively, pre-loaded with IV RL @10ml/kg. fentanyl sedation @1mcg/kg IV in divided doses. Intra-operative hemodynamics, block characteristics, intraoperative complications, pain score and analgesic consumption, postoperative adverse effects, and patient satisfaction with were studied

TSA was performed easily in all the patients, including two patients who complained of paraesthesia. The TSA was effective for surgery in all 19 patients. 4 patients had intra-operative apnoea with only one patient requiring bag and mask ventilation but none requiring conversion to general anaesthesia. 6 patients required mephentermine more than the median dose i.e. 12mg IV. One patient had hypotension with tachycardia and 2 patients had intraoperative bradycardia none required IV atropine. Recovery was uneventful, only 3 patients had complaints of PONV and only 2 patients required IV tramadol (50mg). 16 patients were satisfied with the anaesthesia technique and 3 patients were dissatisfied.

This feasibility study has shown that TSA can be used successfully and effectively for MRM surgery. However, the use of anaesthetic techniques requires experience and great caution.

The ever-increasing popularity of laparoscopic procedures due to its several advantages over open procedure has pushed anesthesiologists to explore anesthetic techniques that can also mitigate the cardiopulmonary risks involved in the use of general anesthesia (GA) for laparoscopy. Regional anesthesia (RA) has emerged as an alternative for these procedures.

A 33-year-old male who underwent laparoscopic cholecystectomy for cholelithiasis under thoracic segmental spinal anesthesia. Under strict asepsis/antisepsis technique, local skin infiltration with lidocaine 1% 3ml was done at T8-T9 intervertebral level, then a Quincke gauge 23 spinal needle was inserted using a paramedian approach until free drainage of CSF was obtained. Isobaric bupivacaine 0.5% 5mg plus a hyperbaric bupivacaine 0.5% 2.5mg with additives of Ketamine 20mg, Dexmedetomidine 10mcg, and Fentanyl 25mcg were administered slowly.

The procedure went uneventful with quick recovery and the patient was discharged the next day. Throughout the patient's hospitalization, close monitoring and follow-up were conducted, and their post-operative course progressed without complications.

Evidence suggests that spinal anesthesia can be safely used in laparoscopy with minimal side effects that can be effectively managed using available pharmacological interventions. RA offers potential advantages over GA, including avoiding airway manipulation, maintaining spontaneous respiration, providing effective post-operative pain relief, reducing post operative pulmonary complications, nausea and vomiting, and promoting early recovery and ambulation.

Laparoscopic cholecystectomy is a minimally-invasive surgery commonly by general anesthesia. Literature suggests that the use of segmental thoracic spinal anesthesia is an effective anesthesia for these types of procedure and is known for adequate pain relief and reduced opioid requirements. This case report aims to discuss the application of segmental thoracic spinal anesthesia for laparoscopic cholecystectomy.

A 59-year-old ASA II female was scheduled for laparoscopic cholecystectomy. Segmental thoracic spinal anesthesia was given using a mixture of Bupivacaine isobaric 5 mg and bupivacaine hyperbaric 2.5 mg, with the following adjuvants— Fentanyl 25 mcg, Ketamine 20 mg, and Dexmedetomidine 10 mcg injected slowly at the T8-T9 interspace using a gauge 23 spinal needle via midline approach. No recorded paresthesias or any problems during puncture or injection of anesthetic were encountered.

After confirming the desired block height of T2, surgery was started. The procedure commenced without any complications. Patient remained comfortable, easily arousable, and responsive during the whole operation and did not require additional sedation intraoperatively. The procedure lasted 2 hours and 9 minutes, with no complaints of poor muscle relaxation from the surgical team. Post-operatively, the patient’s vital signs were well within normal range, and she had no subjective complaints. The patient is also Bromage 0 immediately after the surgery and has no motor or sensory deficits.

Segmental thoracic spinal anesthesia may be a viable option for regional anesthesia in laparoscopic cholecystectomy. It provides effective pain relief, reduces opioid use, and minimizes side effects.

Neuromyelitis Optica Spectrum Disorder (NMOSD) is described as an autoimmune disease causing the inflammation of astrocytes. This demyelinating disease of the central nervous system affects the spinal cord and the optic nerve, causing neuritis of one or another. The effect of local anaesthetics in patients with demyelinating diseases is not as predictable as in healthy patients and might lead to prolonged nerve block duration.

A 51-year-old female patient suffering from Devic´s Disease presented in our anaesthesia clinic prior to hysteroscopy. In the light of her medical history, including COPD and obesity (BMI 36.7, 165 cm, 100 kg), we decided to perform a spinal anaesthesia using a short-acting local anaesthetic in the hope of preventing long block duration. The spinal anaesthesia was performed with a 25G spinal needle and 3.5 ml of Prilocaine 2% (Takipril).

The extent of the block reached TH 8 level, lasting for 5 hours. Against our expectations, the block did not show a sufficient effect as the patient felt uncomfortable having minor pain perception - although the initial expansion of the block began in a typical manner. A general anaesthesia became necessary during the operation. This is in complete contrast to the experiences of her previous spinal anaesthesia, showing a sufficient block with a duration of 20 hours.

Spinal anaesthesia seems to be a viable option for patients with NMOSD. The manifestation of a nerve block remains somewhat unpredictable in this case. Sufentanil or morphine might be expedient adjuncts.

Fast-track programs for hip- and knee arthroplasty require enhanced perioperative care; however, limited research exists on duration of spinal anesthesia with ropivacaine. This observational study aims to evaluate the duration and sufficiency of spinal anesthesia with ropivacaine 15 mg and observe associated postoperative complications.

Initial inclusion of 129 patients undergoing elective hip- and knee arthroplasty received spinal anesthesia with ropivacaine 15 mg. Based on preliminary results, a supplemental group of 27 hip arthroplasty patients receiving a lower dose of 12.5 mg was included. Primary outcomes were duration of the spinal anesthesia measured as time from injection to remission of sensory and motor function. Sensory function was assessed by pinprick test. Motor function was assessed by voluntary movement of ankle-, knee- and hip joints. Secondary outcomes were incidence and timing of associated postoperative complications.

Administration of 15 mg ropivacaine resulted in a median duration of 116 minutes [91-135] until remission of sensory function compared to 90 minutes [75-110] with 12.5 mg ropivacaine (p=0.01). Remission of motor function was 177 minutes [152-222] with 15 mg ropivacaine compared to 146 minutes [115-201] with 12.5 mg ropivacaine (p<0.01). Postoperative complications showed a trend towards increased cerebral- and cardiovascular events among hip-patients.

Spinal anesthesia with 15 mg ropivacaine was sufficient for hip- and knee arthroplasty, and administration of 12.5 mg ropivacaine also seems to be sufficient. Remarkably, remissions were significantly delayed in the operated legs compared to the non-operated legs which is not previously described.

Spinal epidural hematoma is a rare but potentially devastating complication of regional anesthesia. Symptomatic SEH accounts for less than 1% of all spinal space-occupying lesions and affects only 1 per 1 million people annually. The incidence of SEH after neuraxial anesthesia has historically been approximated to be less than 1 in 220,000 patients. We report a case of SEH, to highlight the importance of early diagnosis and surgical intervention.

An 85-year-old patient underwent surgery to repair a medial malleolus fracture, under general anesthesia, after multiple unsuccessful attempts for subarachnoid anesthesia. Past medical history included hypertension, dyslipidemia, hypothyroidism, and lumbar stenosis. On the 2nd postoperative day, she presented with muscle weakness, followed by paraparesis and impaired sensation of the lower limbs bilaterally. The magnetic resonance imaging (MRI) revealed a spinal epidural hematoma compressing the spinal cord toward the L1 vertebral body. On the same day, the patient underwent surgical spinal decompression.

Immediately postoperatively, the patient showed neurological improvement as evidenced by symptoms and imaging improvement and followed rehabilitation protocol. After 3 months follow up, she is discharged from hospital and able to walk with help.

Anesthetists and surgeons, as a team must be alert for the possibility of SEH whenever neurological symptoms occur in the postoperative period, especially after a neuraxial blockade which can be connected to this complication. MRI is the preferred diagnostic method and early surgical intervention is associated with optimal neurological outcomes.

Dexmedetomidine is a centrally acting alpha-2 receptor agonist has different beneficial effects when administered epidurally. This randomized controlled study was designed to demonstrate that epidural dexmedetomidine decrease total dose anesthetics during general anesthesia.

45 patients undergoing general anesthesia for elective colon resection due to cancer were randomly allocated into two groups. Gr.1 had 1 μg·kg-1 dexmedetomidine epidural with ropivacaine 30 mg 25 minutes before induction to general anesthesia and Gr.2 was given fentanyl 100 μg with ropivacaine 30 mg. The depth of anesthesia was guided by BIS with target level between 40 and 60. The consumption of propofol, i.v. fentanyl and muscle relaxants were measured.

22 patients with dexmedetomidine and 23 with fentanyl were enrolled in the study. Patients did not differ by age, p=0,7471. Duration of anesthesia in Gr.1 was 171,7±38 min, and the Gr.2 155,7±45,4, (p=0,4902). The dose of Atracurium was lower in Gr.1 (1,05±0,3 mg/kg) then Gr.2 (1,18±0,4 mg/kg), p=0,6796. Duration of awakening in Gr.1 was longer (16,4±8,2 min) than in Gr.2 (10,7±2,6 min), p=0,0555. BIS values in Gr.1 in the was 41,1±11, and in the Gr.2 45,2±10, p=0,0004. The total dose of propofol was lower in Gr.1 (1,28±0,2 mg/kg) than in Gr.2, (1,77±0,7 mg/kg), p=0,0108. The total dose of fentanyl was less in Gr.1 (5,46±4,4 μg/kg), than in Gr.2 (8,73±3,8 μg/kg), p=0,0171.

epidural dexmedetomidine decreases the doses of propofol and fentanyl during general anesthesia, but increases the duration of awakening time without increasing doses of muscle relaxants.

The mitochondrial disease (chronic progressive external ophthalmoplegia with myopathy) poses many challenges to the anesthetists as eyelid ptosis can be isolated or associated with laryngeal and respiratory muscles affections.

We present a case a-47-year old female with CPEO with myopathy evaluated in anesthesia clinic for Laparoscopic subtotal hysterectomy, she had in addition to eyelid ptosis, difficulty swallowing and choking with liquids, nasal speech and weakness in her arms and pain cramps in her legs. She is also diabetic and hypertensive. Neurological consultation was done with recommendations to avoid paralytic agents and certain mitochondrial metabolized medications. Cardiac and IM consultation was carried out. The impact of her condition on anesthetic approach was discussed with the gynecologist and regional anesthesia was strongly recommended over general Anesthesia. Hence the patient was counseled, and the procedure was changed to Laparotomy under CSE. The full anesthetic techniques were fully explained to the patient.

The intra-operative and postoperative remained uneventful and the patient shifted to PACU pain free.

CPEO with myopathy present limitations to anesthetists. Choosing regional anesthesia with sedation gave a wide range of safety and made the challenging cases easier. Close communication and collaboration between the surgeon and anesthesiologist are essential to ensure the safe and optimal management of such cases.

We present a rare case of total knee arthroplasty in 32 year old down syndrome male patient, ASA 2, hypothyroidism presented with right knee pain scheduled for total knee arthroplasty under regional anesthesia.

Pre anesthesia evaluation was assessed for airway management and best anesthesia plan according to his medical co-morbidities, blood results were within normal range. Cervical spine x-ray was requested. Thyroid function test revealed controlled treatment. His cardiac echo showed: The left ventricle is normal in size. There is normal left ventricular wall thickness. Left ventricular systolic function is normal. Ejection Fraction >55%. Left ventricular diastolic function is normal. The right ventricle is normal in size and function. Mildly thickened Aortic valve leaflet. Mild to moderate aortic regurgitation. His electrocardiogram showed normal sinus rhythm. Our plan for his total knee arthroplasty is under spinal anesthesia along with ultrasound guided adductor canal catheter and IPACK infiltration for postoperative pain control. The duration of surgery lasted for two hours without any complications and 300 ml estimated blood loss and adequate urine output.

He was receiving multimodal analgesia of adductor canal ropivacaine injection daily through the catheter, paracetamol IV, morphine 2 mg IV PRN, NSAIDS once daily. He was discharged home without any complications and he is doing back his daily activities without any chronic knee pain.

As far as we know, this is the first case presentation of total knee arthroplasty in Down syndrome as it is common for hip arthroplasty than knee.

Regional anaesthesia is frequently the preferred anaesthetic technique in cases of predicted difficult airway, as it avoids approaching the patient’s airway. However, choosing the best technique frequently becomes a challenge for some surgeries.

The authors describe the case of a 76-year-old patient undergoing a bilateral breast reduction surgery. She had a history of severe subglotic tracheal stenosis, which required multiple tracheal surgeries.

On the preoperative anaesthesia consultation the patient denied respiratory symptoms, no other predictors of difficult airway were identified and otorhinolaryngology observation did not contraindicate the surgery. Nevertheless, a 4.0mm internal diameter cuffed endotracheal tube was used in previous surgeries and a neck CT scan confirmed a 10x10mm subglotic tracheal stenosis; hence, an epidural anaesthesia with moderate sedation was the choice for the anaesthetic technique. On the day of surgery a thoracic catheter was placed at T5-T6 level and 0,4% ropivacaine and sufentanil were administered with a resulting sensory block from T1 to T8. A combination of ketamine and dexmedetomidine was used for sedation. The procedure was uneventful, with no respiratory adverse events.

Thoracic epidural anaesthesia can avoid the need to manage the airway in cases similar to the one described. However it is not free of complications, including respiratory muscle paralysis with respiratory depression. Therefore, the level of surgical anaesthesia should be carefully tapered. Accompanied procedural sedation should also be regarded cautiously, as the need to maintain airway reflexes and spontaneous breathing is essential.

Hemodynamic instability during general anesthesia or after neuraxial anesthesia in patients with severe cardiac disease is a major concern. Continuous spinal anesthesia offers the advantage to use lower dose of local anesthetic (LA) and titrate as needed while maintaining hemodynamic stability. In this report, we describe the use of ultra‐low‐dose continuous subarachnoid block for an urgent hip hemiarthroplasty.

A 87-year-old male patient, ASA physical status IV, with hypertension, diabetes mellitus, hypercholesterolemia, severe peripheral arterial disease, symptomatic severe aortic stenosis (valvular area 0,72cm2) and disseminated prostate cancer. He was proposed to urgent hip hemiarthroplasty. The patient and his family were informed about the high risk of the procedure and the consent form was obtained. ASA standard monitoring with invasive blood pressure monitoring was established. A catheter was introduced 3 cm in the subarachnoid space with a paramedian approach and 10mcg of fentanyl and 2 mg of isobaric bupivacaine 0,5% were administered through the subarachnoid catheter.

The surgery was performed in the left lateral position and lasted 70 minutes without need for further intrathecal administrations. There was requirement for small boluses of ephedrine due to progressive blood pressure drop during the procedure. The catheter was removed in the PACU. Postoperatory period was uneventful and the patient was discharged after 4 days.

In patients with severe cardiovascular disease, titration of lower doses of LA in continuous subarachnoid block allows a safer procedure.

Neuraxial anaesthesia for caesearean section (CS) with local anaesthetics is frequently performed, however these procedures can cause high-level blockade or Local Anaesthetic Systemic Toxicity (LAST). Evidence supporting the use of intralipid as a reversal agent following high-spinals is scarce.

This case series presents the reversal of two patients with high spinal blocks with intralipid emulsion. Written consent was obtained.

Case 1: A 27-year-old primigravid at 40 weeks 3 days of gestation was referred for a CS following foetal distress and slow labour progression. 2% lignocaine was given epidurally in 5ml aliquots (Total 20ml over 45 minutes). Postoperatively, the patient had increased work of breathing, hypotension, and bilateral upper arm weakness. This persisted for 50 minutes with block to ice at C2 bilaterally. Intralipid emulsion was given in 5-10ml alliquots (Total 50ml). Rapid block recession to T4 bilaterally within 15mins. Case 2: A 26-year-old primigravid at 38 weeks and 2 days gestation was referred for a CS due to obstructed labour. An epidural performed earlier only provided a unilateral block. A spinal neuraxial was performed. Block to ice was noted at C7 after delivery, with hypotension and increased work of breathing. 20ml of Intralipid was given, with block recession to T1. A second 20ml intralipid bolus was given and the block recessed to T4.

Early intralipid administration rapidly reverse neuraxial anaesthesia and prevent LAST. This study supports the safe use of intralipid. Future research is required to investigate the appropriate timing and dosing of intralipid when used in such circumstances.

While in Western countries, unilateral spinal anesthesia has been widely practiced for a long time, it remains little known in the local anesthesia community, and has not been the object of many studies. However, it is a simple, practical and effective technique. Our objective was to evaluate this practice in emergency anesthesia management in frail patients and to compare it with conventional spinal anesthesia.

This is a prospective, observational, comparative study between hypobaric unilateral and conventional spinal anaesthesia for hip fracture surgery carried out in the operating room of the university military hospital of Staoueli. The work was spread over of 12-month period from 2019 to 2020. The parameters analyzed were hemodynamic variations, vasopressor use, block efficiency, postoperative adverse events, and postoperative morphine consumption.

-75 cases (mean age 72±14 years) -Group1= 41 patients (54.6%) divided into (ASA1=14.6% ASA2=60.98% ASA3=24.39%) single shoot spinal anaesthesia -Group2= 34 patients (45.3%) divided into (ASA1=2.9%, ASA2=26.4% ASA3=61.7%, ASA4=8.8%) unilateral hypobaric spinal anesthesia. -Hemodynamic variations were more severe in group 1 (51% hypotension) compared to 30% in group 2 RR=1.69 and odds ratio=2.4 -these variations were more marked in the ASA3 subgroup (group 1=70% hypotension versus group 2=30%) with an RR=2.33 and an odds ratio=5.44 -39% of group 1 required vasoactive drugs (15mg +/- 11) versus 32% of group 2 (8mg+/- 6.49) - no difference in the use of morphine in post-op.

Within the limits of the population studied, this work demonstrates the clinical value of unilateral spinal anesthesia in ortho-trauma surgery in the frail patient.

Vertical nystagmus is generally associated with cerebellar or brainstem injuries. The most frequently reported complications associated with opioids administered via epidural include nausea and vomiting, itching, and respiratory depression. We describe a clinical case of vertical nystagmus following epidural morphine administration.

A 76-year-old patient underwent bilateral breast reduction mammoplasty under thoracic epidural anesthesia with moderate sedation. In the postoperative period, after receiving 2 mg of morphine through the epidural catheter, she developed nausea and vomiting accompanied by visual perception changes. Neurological examination revealed a baseline and gaze-evoked vertical rotary nystagmus without other deficits. A computed tomography scan of the brain showed no acute changes. Assuming iatrogenic opioid-induced nystagmus, a dose of 0.1 mg of naloxone was administered, resulting in complete reversal of the symptoms.

Cases of nystagmus associated with epidural opioid administration are rare, with only two cases reported in the literature. In the presence of this neurological alteration, it is important to differentiate between structural cerebellar lesions and toxic/pharmacological causes.

The resolution of symptoms following naloxone administration confirms the diagnosis of a pharmacological iatrogenic cause of vertical nystagmus.

To compare the efficacy and tolerability of 0.5% Racemic mixture Bupivacaine, 0.5% Levobupivacaine and 0.75% Ropivacaine, in patients undergoing lower abdominal surgery.

84 patients, ASA grade 1 and 2, were randomized to receive an epidural injection of study drug, 17 ml of 0.5% Levobupivacaine in Group L or 17 ml 0.5% Racemic mixture Bupivacaine in group B or 17 ml of 0.75% Ropivacaine in group R.

The mean time for onset of sensory block is faster in R group when compared to group L and B (p Value <0.05). The maximum dermatome reached (higher), the time taken to attain maximum sensory level, the two segment regression and the duration for regression of sensory block to T10 were faster in group R. Total duration of analgesia in R group was 301.96 versus 222.86 in B group versus 319.29 min in group L (p value <0.05).The time for complete reversal of sensory block was 345.54 in R group versus 400.71 in B group versus 418.95 min in group L ( p value <0.05). The onset of motor block and duration of motor block were comparable in both the groups. The regression of motor block and grade attained were significantly different among three groups. The time taken to attain the maximum motor blockade was 40.18 in R group versus 23.57 in group B versus 17.86 min in group L .(p value <0.04).

All three isomers produced effective and well tolerated epidural anaesthesia for patients undergoing lower abdominal surgery.

To compare the efficacy and tolerability of 0.5% Racemic mixture Bupivacaine and 0.75% Ropivacaine, in patients undergoing lower abdominal surgery.

56 patients, ASA grade 1 and 2, were randomized to receive an epidural injection of study drug, 17 ml 0.5% Racemic mixture Bupivacaine in group B or 17 ml of 0.75% Ropivacaine in group R.

The mean time for onset of sensory block is faster in R group (p Value 0.004). The maximum dermatome reached, the time taken to attain maximum sensory level, the two segment regression and the duration for regression of sensory block to T10 was similar in group R and group B. Total duration of analgesia in R group was 301.96 min versus 222.86 min in B group (p value 0.01).The time for complete reversal of sensory block was 345.54 min in R group versus 400.71 min in B group ( p value 0.001). The onset of motor block and grade in both groups were similar. The regression of motor block was faster (p Value 0.02) and total duration of motor block shorter (p value 0.04) in Group R. The time taken to attain the maximum motor blockade was 40.18 min in R group versus 23.57 min in group B. (p value <0.05). The mean duration of motor block in R group was 146.25 min and in B group it was 172.78 min. (p value <0.05).

Both 0.5% Racemic mixture Bupivacaine and 0.75% Ropivacaine produced effective and well tolerated epidural anaesthesia for patients undergoing lower abdominal surgery.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematopoietic stem cell disorder characterized by the presence of abnormal red blood cells and an increased risk of hemolysis.

The case involved an 83-year-old man with a left humeral neck fracture who had been diagnosed and treated for PNH for 10 years. The patient was a high-risk patient with a history of both hemolytic and thrombotic symptoms, which were suppressed by treatment with the monoclonal antibody eculizumab. Surgery was performed with an intramedullary nail through the proximal end of the humerus. Given the exacerbation of PNH, light sedation with midazolam and a superior nerve trunk block with 5 mL of 0.5% levobupivacaine was performed. No significant exacerbation of PNH symptoms or hematoma formation was observed. He was discharged from the hospital on postoperative day 2.

There are no reports of surgical experience with peripheral nerve blocks in patients with PNH. Anesthetics or high-dose opioids for surgical management should be a risk factor for an episode of hemoglobinuria by sleep induction, as nocturnal exacerbation of hemoglobinuria has been attributed to carbon dioxide retention and blood acidosis leading to complement activation. Because the superior nerve trunk block is a superficial technique among brachial plexus blocks, the risk of hematoma formation was considered low. Treatment with monoclonal antibody could have facilitated the management of the disease and avoided perioperative problems.

We experienced a case of PNH patient who underwent humeral head fracture surgery under regional anesthesia and light sedation.

The pericapsular nerve group (PENG) block is a novel regional analgesia technique to reduce pain after hip fracture surgery (1, 2). PENG blocks may be superior to fascia iliaca blocks for post-operative analgesia and its motor-sparing effects (2-4). This case series aimed to explore the feasibility of introducing the PENG block into a local enhanced recovery protocol for trauma patients with hip fracture.

The case series was performed prospectively between January and April 2023 for 25 consecutive trauma patients undergoing hip fracture surgery in a UK district general hospital. All patients were consented prior to surgery to receive the PENG block alongside general anaesthesia or spinal anaesthesia. The use of intra-operative opioids and rescue opioids in recovery were collected. Subsequent oral opioid consumption and early mobilisation status were noted at 24 hours.

15 out of 25 patients received general anaesthesia with the remainder receiving a spinal anaesthetic. Intravenous fentanyl was administered to all patients intraoperatively, with a mean of 115 micrograms. 5 patients required intraoperative alfentanil and morphine in the recovery area. 6 patients did not require oral opioids in the subsequent 24 hour period; the remainder of patients were administered a range of oral opioids from 2.5mg to 10mg (morphine or oxycodone). All patients had early mobilisation within 24 hours of surgery.

Locally, the PENG block is a feasible alternative to fascia iliaca blocks, providing effective analgesia perioperatively and promoting early mobilisation. Further randomised controlled studies are required to examine the efficacy of PENG blocks in hip fractures.

Currently there is little published in the use of popliteal sciatic blocks (PSB) during distal limb angioplasty procedures in awake patients. We present a case directly comparing angioplasty under local anaesthetic alone, versus with PSB. A 70-year-old, ASA 3, male patient was scheduled for a tibial angioplasty, having undergone the same procedure on the contralateral leg a week prior. During pre-assessment, he reported experiencing unexpectedly severe pain during multiple arterial balloon dilatations in the first procedure. We offered a PSB for the second procedure, with the potential for alleviating intra-operative pain.

We performed an ultrasound guided PSB of the right leg with 20ml of 0.75% Ropivicaine, which the patient tolerated well. We then surveyed the patient and the surgeons after the operation.

Intra-operatively, the patient did not show any signs of distress during arterial balloon dilatations, actually sleeping through most of the 2-hour procedure. Post-operatively, he reported his pain was 0/10 during the procedure versus 9/10 for his previous angioplasty (without PSB). He stated it was the “obvious choice” to have a PSB for tibial angioplasty and was “surprised the PSB was not offered the first time”. Furthermore, the surgeon (who had performed both procedures) reported better, “incomparable” operative conditions with PSB, as the patient was pain free and “more still”.

This case demonstrates a clear advantage of PSB for tibial angioplasty for both patient and surgeons. These benefits have translated to surgeons at our institution increasingly requesting PSB for these operations.

We reviewed our current practice for free fibular flap reconstruction in head and neck surgery at the Fiona Stanley Hospital, Perth, Australia. Our aim was to investigate if a popliteal sciatic block, single shot or with catheter infusion, reduces the need for opioids on day 1 and day 2 postoperatively.

We performed a retrospective audit for patients who underwent free fibula flap surgery between 05/09/2019 and 02/07/2021. The data was collected from the BOSSNET Digital Health Records database and analysed in Microsoft Excel. WA Health GEKO Audit approval number 46463.

A total of 30 patients were included. 14 patients received no regional anaesthesia, 5 patients received a single shot sciatic popliteal block and 11 had a regional catheter with continuous ropivacaine infusion. For the first 24h postoperatively, total use of IV fentanyl was lower where regional anaesthesia was applied, P=0.617. Similar results were found on day 2 postoperatively. Oxycodone consumption was lower overall in the regional group, especially when a continuous infusion was used, P=0.697. There were no adverse reactions in patients with regional anaesthesia.

Overall, we found a reduction in opioid requirements during the first 48h after surgery with regional anaesthesia. However, with no statistical significance. Any reduction in opioid consumption is beneficial due to the known short- and long- term adverse effects of opioids. In the absence of any signal of harm, we opine that a popliteal sciatic block is useful for multimodal analgesia in free fibula flap surgery.

A 52-year old male patient, diagnosed with End Stage Renal Disease, came in with a complaint of infected left radiocephalic arteriovenous fistula for renal dialysis access. The site was noted to be erythematous, tender and with abscess formation. The plan was to ligate the fistula under peripheral nerve block.

The anesthetic plan for this patient was a left supraclavicular nerve (SCN) block, to which the patient consented. After aseptic technique, an in-plane ultrasound-guided left supraclavicular block was performed using high‑frequency linear transducer above the middle third of the clavicle. A total of 25 ml of Ropivacaine 0.25% with dexamethasone 8mg was injected.

A 23-minute soaking time achieved a surgical anesthesia to the operative site. The patient also complained of hoarseness. His hemodynamic parameters were normal, no desaturation, no difficulty of breathing, and no agitation. The patient was reassured then sedated to a Modified Ramsay Sedation Score of 3. The surgery was completed in 57 minutes. Still, with hoarseness noted. He was pain-free for 12 hours. The hoarseness was resolved as soon as the block diminished.

The recurrent laryngeal nerve (RLN) block is common following an interscalene block, but is quite unsual after a SCN block. RLN block has been reported in 1.3% of cases but almost exclusively occur in right SCN block (Gupta,et.al). Hoarseness after left SCN block is attributable to the blockade of fibers of RLN in the left vagus nerve, where the drug deposited moved medially to the left subclavian artery where the vagus nerve sits in proximity.

In replantation surgery maintenance of limb perfusion and adequate analgesia are critical. Since regional anesthesia can offer pain control and vasodilation it plays an important part in this patient managing.1 These are long-lasting surgeries, there is sometimes a fear of using a single shot as anesthetic technique. The median duration of ropicacaíne induced anesthesic block varies between 4-8h.2 We report 4 cases of finger reimplantation surgeries performed under brachial plexus (BP) block without using any adjuvant.

We describe 4 cases in which an alternative approach to axillary BP block was performed, under ultrasound-guidance, as anesthetic technique. After visualization of the median, the ulnar and the radial nerves, 10 mL of ropivacaine 0.5% was distributed around them. Then, a distal scan was performed and another 10 ml were administered when the 3 nerves were no longer surrounded by local anesthetic. A propofol perfusion was used to light sedation.

Surgeries lasted on average 8.6 hours and proceeded uneventful.

Balance between anesthesia, analgesia and peripheral vasodilatation is not always easy since systemic agents used in general anesthesia and systemic analgesics may decrease median blood pressure and impair limb perfusion. The same happens when adrenaline is used as adjuvant to prolong peripheral blocks. With this case series we were able to show that with a single shot BP block it is possible to safely perform a 9 hour surgery without use of any adjuvant, taking advantage of all the benefits of the sympathetic block and analgesia associated with this technique.

Prosthetic joint infections can be challenging to treat and often require surgical intervention. We present a case of arthroscopic knee washout performed under peripheral nerve blocks due to the high risks of general and neuraxial anaesthesia.

A 75 year old lady presented with an infected prosthesis, two years post total knee arthroplasty. She had a BMI of 40, hypertension, TIA one year ago (currently on Clopidogrel), moderate obstructive spirometry (FEV1 72% predicted), ASD repair 40 years ago and suspicion of pulmonary hypertension on CT thorax. She was positive for COVID-19 on admission. Surgical debridement was delayed due to the risks of both general and regional anaesthesia given her COVID status and anti-platelet medication. Clopidogrel was stopped and she was treated with IV antibiotics. After two days she was at risk of deteriorating; she had significantly elevated inflammatory markers and was repeatedly spiking temperatures. Given her ongoing anaesthetic risks we consented her to have a joint washout under awake peripheral nerve blocks. Ultrasound guided femoral and popliteal nerve blocks were performed with 16ml and 20ml 1% Prilocaine respectively. Aliquots of alfentanil were required intermittently during the procedure to a total of 800mcg, and the patient was reassured throughout.

Arthroscopic washout was successfully performed in this patient under femoral and popliteal nerve blocks using 1% Prilocaine, with supplemental intravenous analgesia.

Peripheral nerve blocks can be used for washout of infected knee joints, allowing time for optimisation before definitive surgical intervention under neuraxial or general anaesthesia.

Pure Autonomic Failure (PAF) is a rare neurodegenerative disease of the autonomic nervous system. The etiology is unknown but its pathophysiology involves the accumulation of a protein, called Lewy bodies, in the cells of autonomic nerves, leading to reduced norepinephrine production and release. Therefore, the main symptom of PAF is orthostatic hypotension, but it can also present bladder dysfunction, constipation, anhidrosis and sleep disorders. We describe the successful anesthetic management of a patient with PAF.

A 68 year old man, ASA physical status III, was scheduled for unicompartmental knee prosthesis surgery. He was diagnosed with PAF 5 years before due to orthostatic hypotension, neurogenic bladder, erectile dysfunction, hyposmia and REM sleep behavior disorder. An arterial line and central venous catheter were placed. We performed regional anesthesia with femoral, sciatic, obturator and lateral cutaneous nerve blocks guided by ultrasound and neurostimulation.

The surgery took about 1 hour and went out uneventfully with no need to administer vasoactive drugs. The patient was transferred to the intermediate care unit and was discharged home on post-operative day 4.

PAF is a rare disease that can present challenges to the Anaesthesiologist. General management must focus on ensuring hemodynamic stability perioperatively. In this clinical case, we demonstrate that regional anesthesia with peripheral nerve blocks can be an effective and safe anesthetic option. Further considerations include: exaggerated or unpredictable response to vasopressors, decreased clearance of drugs with liver metabolism (such as amino amide local anesthetics) and avoidance of prolonged postoperative inactivity.

Hallux valgus (HV) surgery is associated with severe postoperative pain, requiring an anesthetic-analgesic strategy based on peripheral nerve blocks (PNB). Our goal was to assess the anesthetic strategy and postoperative pain control in HV ambulatory surgery.

A descriptive observational retrospective study was designed and included 49 patients in 2021 at Hospital de la Santa Creu i Sant Pau, Spain. Anesthetic techniques, time to discharge and postoperative pain at 24 hours of surgery were collected. Ethical approval was taken from Institut d'Investigació Biomèdica Sant Pau (IIBSP-HAL-2023-62).

The most used anesthetic technique was PNB in 95.92%: Ankle block (AB), sciatic popliteal block (SPB) with posterior tibial nerve block (PTB) and SPB exclusively. Only 6.4% of patients required general anesthesia due to a failed blockade. No patient required opioids as rescue analgesia. The median hospital discharge time was 115 minutes (92.5 min for AB versus 120 min for other PNB), with no statistically significant differences. At discharge, all patients reported NPRS scores of 0. On the day after, 65,3% (n=32) of patients reported NPRS score. Both techniques were effective in achieving mild pain (NPRS 2).

The utilization of PNB for HV ambulatory surgery led to favourable analgesic outcomes and low complication rates. The most frequent PNB was the AB (77.5%), with adjuvants added in 57.89% of patients, achieving effective postoperative analgesia without motor block, which should have facilitated earlier discharge. However, our findings suggest that further improvements to our outpatient surgery pathway are needed, as we did not observe differences in discharge times.

Allergy to muscular relaxants is still a big concern to Anesthesiologists. This case discusses interscalene block as an alternative to General Anesthesia in a patient with confirmed allergy to Rocuronium and Cisatracurium.

We report a case of 73-year-old female, ASA III, with positive skin tests to Rocuronium and Cisatracurium. Patient had a humeral fracture and was proposed for a Total Shoulder Arthroplasty. Anesthetic plan was discussed with the patient prior to the procedure and informed consent was obtained. After monitoring, the patient was given intravenous fentanyl 0,05 mg and midazolam 1mg and a dexmedetomidine perfusion was initiated. An ultrasound guided interscalene brachial plexus block (ISB) and cervical plexus block (CBP) were performed using 15 mL of ropivacaine 0,5% and mepivacaine 0,6% and 5mL of ropivacaine 0,5% and mepivacaine 0,6%, respectively. Patient was positioned in beach chair. Skin incision was made 20 minutes after local anesthetic injection. Surgery lasted for 1 hour and 30 minutes, and the patient only referred mild discomfort due to the sitting position nearly the end of the surgery. Patient controlled analgesia with intravenous morphine and ketamine was used post-operatively.

There were no complications, and patient demonstrated high level of satisfaction.

Positivity of skin test reaction to neuromuscular blocking agents makes their use unsafe. A CPB along with an ISB can provide anesthesia to the roots C2 to C4 and C5 to C7, respectively. Together they represent an alternative anesthetic technique to General Anesthesia for shoulder surgery.

Regional blocks can decrease incident pain in derby patients with hip fracture especially when position for neuroaxial anesthesia. This study aimed to evaluate the pattern of dye distribution following an ultrasound guided anterior hip capsule block injection in human cadavers and the analgesic effect of this block on patients with fractured hip when positioning upright fo spinal anesthesia.

Following a 10ml methylene blue contrast bolus injection in 12 fresh cryopreserved cadavers,injectate spread in the hips was analyzed by computed sonography in transversal anatomical sections. In the clinical phase , anterior hip capsule block was performed with 10 ml of 0,2% ropivacaine in 25 patients with hip fracture and its analgesic efficacy was assessed by pain score using Visual Analog Scale (VAS).

Contrast dye distribution and ethylene blue staining was extensive starting from site of injection and spread cephalic along the iliopsoas muscle suprainguinally to th pelvis and caudal to the lesser trochanter of the femur. Patients reported significant pain relief within 10 min of local anesthetic injection. VAS pain score reduced from 2,8 -2,1 t 1,2-1,4( p: 0,002) and was 2,2+-2 when positioned upright for spinal anesthesia. Pain score remained low ( 1,9+- 1,8)and 92% required no additional systemic analgesic rescue for next 24h.

Ultrasound guide anterior hip joint capsule block injection produces idspread peri-capsular and peri-muscular injectate spread in the vicinity of th olio-psoas muscle. This block provides effective analgesia in patients undergoing fractured hip surgery both for positioning for performance of neuoaxial anesthesia and in the postoperative period

The 2021 curriculum for anaesthetists in training in the United Kingdom recognises the importance of regional anaesthesia. All anaesthetists in training are now expected to be able to perform regional anaesthesia to the abdominal wall, chest wall, lower limb and upper limb independently by the end of their training . The Regional Anaesthesia UK (RA-UK) Plan A blocks documents provide a framework for regional anaesthetic techniques covering each region of the body. We wanted to assess the readiness of our department to be able to perform and / or teach these skills.

We designed an anonymous questionnaire to assess the readiness of permanent staff members within our department to perform and teach each technique listed in the RA-UK plan A blocks, including catheter techniques.

62 responses were received. Of these, 47 were from consultants or locally employed doctors who would be expected to supervise trainees during their daily work. Table 1 demonstrates that, In our institution we identified a high proportion of permanent staff members able to teach the upper and lower limb plan A blocks, but a much lower confidence level with trunk blocks.

This survey demonstrates the need to focus on training of the permanent staff body in plan A trunk blocks in particular before we can reliably teach anaesthetists in training. 92% respondents felt future departmental teaching / sessions on scanning and teaching on Plan A blocks would be helpful for their development, including the use of perineural / fascial plane catheter techniques.

Evaluate the benefits of a long-acting analgesic block of the median and radial nerves at the elbow, combined with a short-acting brachial plexus block at the axillary level, for the management of anesthesia and postoperative analgesia in surgical treatment of wrist fracture.

After approval from the Ethics Committee, patients scheduled for wrist fracture surgery under regional anesthesia were included in this prospective, randomized study. They were divided into two groups: BAX group alone (ultrasound-guided axillary block 0.5% Ropivacaine) versus BAX asso (axillary block 1.5% Lidocaine + median and radial blocks 0.5% Ropivacaine). Postoperative analgesia duration, opioid consumption during 48 hours postoperatively, incidence of complications, and time to motor function recovery of the elbow were recorded.

150 patients were included and randomized in the study and 106 being included in the primary per-protocol analysis. The recovery time of forearm flexion was significantly shorter in the BAX-Asso group 4(2-6) hours vs 15(11-19) hours (p<0.001). The success of the block assessed at 30 minutes by sensory-motor tests was comparable in both groups: 93% BAX vs. 98% BAX-Asso(p=0.2). However, the anesthesia setup was faster in the BAX-Asso group compared to the BAX-Alone group. No significant difference was found in postoperative analgesia and consumption of morphine.

The implementation of a short-acting anesthetic axillary block combined with long-acting analgesic blocks at the elbow compared to a long-acting axillary block appears to enhance the patient's journey. Early motor recovery without compromising the quality of postoperative analgesia, was the main findings of the BAX-Asso study.

Various anesthesia techniques are available for achilles tendon repair (general, spinal or regional anesthesia). The prone position can be a limitation. This study aims to assess the feasibility of combining sciatic nerve block and wide awake local anesthesia with no tourniquet (WALANT) for anesthesia during Achilles tendon rupture repair.

Patients undergoing Achilles tendon suture were included from 2022 to 2023. Ethical approval from the SFAR Ethics Committee was obtained. Demographic data were collected. Sciatic nerve block (15 ml of 0.375% ropivacaine) and WALANT (30 ml of 1% lidocaine adrenaline on either site of achilles tendon) were performed under ultrasound guidance with patient in prone position. The primary outcomes were the quality of chemical garroting with WALANT and the need for sedation or GA. Postoperative pain, surgical and hospitalization durations were recorded.

Thirty-nine patients were included, with a median age of 40 years, 90% male, and 77% ASA 1. Five tourniquets were inflated, all before the beginning of the procedure at the surgeon's request. Three patients required sedation: 2 for anxiolysis and 1 due to technique failure with pain experienced by the patient. Thirty-five patients did not require postoperative visits to the post-anesthesia care unit, while 4 did. The median PACU time for the cohort was 0 [0.00,0.00]minutes, with a median time of 46[30,59] minutes for patients who visited the PACU. The median postoperative pain score was 0/10[0, 0].

Combining WALANT and sciatic nerve block provides effective anesthesia for Achilles tendon repair surgery and eliminates the need for a pneumatic tourniquet.

Awake craniotomy is most commonly preferred in tumor resections that may cause neurological sequelae, arteriovenous malformation surgery, and deep brain stimulation applications such as Parkinson's disease. This case report describes an awake craniotomy performed with a monitored anesthesia care method in a high-risk patient with severe COVID-19 pneumonia.

A 61-year-old male patient with known hypertension, diabetes, and coronary artery disease was isolated at home and diagnosed with SARS-CoV2 infection. The patient had a subdural hematoma due to head trauma as a result of sudden loss of consciousness(Figure-1). He was unconscious (GCS:10 points). Due to his hypoxic condition and severe pneumonia(Figure-2), operation was considered high-risk, and awake craniotomy was planned. He had respiratory rate of 46/min; heart rate of 88/min; blood pressure of 160/69mmHg, and oxygen saturation 86% with 4lt/min oxygen. Initially, a loading dose of dexmedetomidine was given as 1mcg/kg/100cc IV infusions for 15 minutes. Then, invasive blood pressure monitoring and bilateral scalp block with 0.5% bupivacaine were performed. The patient was sedated with dexmedetomidine infusion until end of operation. The operation, without any complications, was completed in 40 minutes.

Scalp block takes first place in craniotomy analgesia and also provides hemodynamic stability. It is known that dexmedetomidine is an excellent alternative to propofol for sedoanalgesia. Therefore, the main reason for preferring the awake craniotomy method is that the patient has severe pneumonia.

Awake craniotomy requires multidisciplinary teamwork and personal experience. Dexmedetomidine remains an indispensable agent of awake craniotomy with its anxiolytic and analgesic properties and minimal respiratory depression effect.

The goal of case report is the management of awake craniotomy with sleep-awake-awake tecnique. An awake craniotomy is a surgical procedure in which patient is deliberately kept awake during whole surgical process or a portion of surgery.

The patient was a 49-year-old male; MRI revealed a 42x38 mm glial tumor in the temporal region, close to Broca area, in the structures of the neurosurgery clinic with a complaint of headache. A craniotomy with scalp block was planned for the patient. Consent was obtained after preoperative information was given. Standard anesthesia monitoring(ASA) was performed on the patient. We planned the sleep-awake-awake technique in awake craniotomy. In induction, 2.5mg/kg of propofol, 1.5mcg/kg of fentanyl and 1mg/kg of lidocaine were administered. A supraglottic airway device, I-gel, is inserted. Then, scalp block was performed with 0.5% bupivacaine. Neurosurgeon applied Mayfield pine. As neurosurgeon approached where the tumor was located, the stage of awakening the birth was started. Before these steps, a loading dose of dexmedetomidine 1mcg/kg was given as a 15-minute infusion in 100cc fluid, and 0.2mcg/kg/hour was switched to maintenance. Remifentanil and sevoflurane are reduced and turned off after 15minutes. The patient whose spontaneous breathing started was awakened, and i-gel laryngeal mask was removed. The patient was talked to every 3-5 minutes until the tumor area was reached and controlled by starting the engine. The patient would talk long enough to answer the questions.

Awake craniotomy is multidisciplinary teamwork, and the anesthesiologist should know for various purposes, scalp blockage, and forward referral management.

Different regional anaesthesia (RA) techniques are used for the distal upper limb. However, the best RA technique for distal upper limb surgery is not well recognised. In this systematic review, we aimed to evaluate randomized controlled trials (RCTs) comparing axillary block (AB) to other RA techniques for distal upper limb surgery.

A systematic review was conducted searching in the following databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and CENTRAL between 1990 and 2022. We included only RCTs that compared AB with other approaches to brachial plexus blockade (interscalene block, supraclavicular block, infraclavicular block, mid-humeral block, coracoid block), distal peripheral forearm nerve block, intravenous regional anaesthesia (IVRA), and Wide-awake, local anaesthesia, no tourniquet (WALANT) technique.

Primary outcome was adequate surgical anaesthesia after 30 minutes of block completion. Secondary outcomes included amongst other things the block performance time, and complications related to the block.

AB is a feasible and safe RA technique for distal upper limb surgery. Meta-analysis of the adequate surgical anaesthesia at 30 minutes shows that US-guided infraclavicular block (ICB) has a superiority over the US-guided ABPB ( 95% CI [0.284, 1.350], P < 0.003). Meta-analysis of performance time shows US-guided ICB to be shorter (95% CI [-3.198, 0.333], P < 0.016). This holds true when comparing NS-guided techniques and US-guided techniques separately. However, the risk of complications is lower in AB. High heterogeneity is found in local anaesthetic mixtures and volumes, potentially causing part of the differences.

Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in perioperative pain management for open abdominal surgery. In patients presenting with sepsis there is a concern with possible dissemination of the infection, hemodynamic instability and coagulopathy development in the context of sepsis. With this in mind, we should have different options for pain control.

A 65-year-old female patient was proposed for an urgent exploratory laparotomy due to anastomotic leak after an enterectomy. She presented with fever and hypotension and was receiving antibiotic therapy. Due to the concern of her condition worsening, it was decided not to perform an epidural block. In alternative, a bilateral erector spinal plane block was done before induction of total intravenous general anesthesia.

The surgery lasted 2 hours, and the patient remained hemodynamically stable. As a multimodal analgesia strategy, she received dexamethasone, acetaminophen, ketorolac, and ketamine. At the end of the surgery, the patient woke up comfortable and only needed a small bolus of intravenous morphine in the immediate post-operative period. She was evaluated by an anesthesiologist at 24 hours, with only mild pain with movement.

Peripheral nerve blocks (PNB) are a possible alternative when it’s decided to not perform an epidural block for laparotomies. By doing so, we can achieve a multimodal analgesic strategy without the risks associated with neuraxial approaches. In this case, we were able to provide comfort for the patient by resorting to less common PNB.

Erector spinae plane block (ESPB) has been used successfully in chronic shoulder pain management, however ESPB has not been widelly used as a postoperative analgesia in shoulder surgeries. The aim of this case presentation was to describe the use of bilateral high thoracic erector spinae plane block for provision of analgesia for bilateral single staged shoulder arthroplasty.

66 years old patient, ASA score II, underwent bilateral single staged shoulder arthroplasty due to sustained trauma. Bilateral ESPB at T2-T3 level was performed with 20ml of 0,375% levobupivacaine before standard general anesthesia induction for postoperative analgesia. Informed consent was obtained for reporting this case report. Sheduled postoperative patient analgesia was paracetamol 1g every 8h and ketorolac 30mg every 8h. Postoperative pain scores were recorded with numerical rating scale (NRS) on the 1st, 2nd, 4th, 8th, 16th, 24th and 48th hour after the procedure. Opiod consumption and adverse effects ( nausea, vomiting, respiratory failure, hematoma ) were also recorded.

The postoperative NRS scores: for the 1,2,4th hour were 0-2, for the 8th hour 8 and as a rescue analgesia for the breakthrough pain tramadol 100mg was administred, for the 16th 3, 24 and 48th hour were 0-1. Total 48 hours tramadol consumption was 100mg and no aditional opiod. No side effects or complications related to the block were noticed.

Ultrasound guided high thoracic erector spinae plane block can provide effective analgesia in shoulder surgery. As a phrenic nerve sparing block it can be alternative to routinely used interscalene block.

Historically, performing bilateral interscalenic block was an absolute contraindication due to the risk of phrenic nerve paralysis. There are few cases in literature, without clear uniformity in volume and concentration of local anaesthestic, the most performed by neurostimulator. We describe a clinical case of echoguided bilateral analgesic interscalenic block for total shoulder arthroplasty, to control intense postoperative pain.

We performed an interscalenic bilateral block in a 52 years old patient, ASA 2 with bilateral dislocation and fractures of proximal epiphysis of humerus. He did not have any respiratory comorbidities. The surgery was started under balanced general anesthesia, using remifentanil for analgesic management. At the end of surgery, we perform bilateral block using low volume of anaesthetic, 7 ml each side of ropivacaine 0,375%, visualizing echographically plexus roots and the spread between c5-c7.

The patient did not show any respiratory complication after extubation The study of diaphragm excursion did not show any phrenic disfunction. We administered multimodal analgesia without opioids needing. His Numeric Rating Scale was 0 at extubation, 3 at 12 and 24 hours from surgery. The patient had never showed signs of respiratory failure, and never had a saturation lower than 98%.

After surgery, we only could approach brachial plexus in interscalenic site, avoiding suprascapular block because of difficult posterior approach. The use of ecography leads to reduction of volume and concentration, and could lead to deep change in classic absolute contraindications of peripheral anaesthesia.

Buerger’s disease is a non-arteriosclerotic segmental inflammatory occlusive vasculitis of small vessels, typically affecting the extremities. The main goal of treatment is to improve blood flow to the affected tissues, which can be achieved by reducing the activity of the sympathetic nervous system. One effective method for achieving this is through the use of brachial plexus block, which blocks sympathetic fibers and promotes vasodilatation.

36-year-old man, complaining of pain and trophic lesions in the extremities of the first and second fingers of the right hand with 1 month of evolution. Upon admission he reports pain 10/10 on the numerical rating scale, which has prevented him from sleeping for the last few days. We performed a brachial plexus block, supraclavicular approach and started patient controlled regional analgesia with Ropivacaine 0.2% 15ml every 4hours, 10ml bolus with 1hour lockout. He also started Alprostadil and Enoxaparin.

Patient always reported intensity less than 2/10 and he mentioned that since we performed theblock he was able to sleep again. Seven days after the treatment initiation, the signs attributed to poor perfusion in fingers regressed significantly and on the 14th day, no signs of poor perfusion were observed.

We concluded that the brachial plexus block ensured the return of the patient's quality of life by greatly reducing the intensity of the pain and providing him with the possibility of being able to sleep. Furthermore, we believe that the contribution of the brachial plexus block was decisive for the success of the treatment.

Patients in Resource-Limited Settings (RLS) have substandard access to anesthesia-related medical practices and trained practitioners, yielding high rates of perioperative complications and poor pain management. Literature suggests that regional anesthesia shortages and inefficiencies are imminent worldwide. This study is a continuation of prior research in Ghana wherein the Global Regional Anesthesia Curricular Engagement (GRACE) curriculum was developed. The curriculum was implemented at Osmania General Hospital (OGH) in Telangana, India, during COVID-19 to establish the training model in a different socio-cultural setting and emphasize GRACE’s use in various RLS.

After an initial needs assessment in 2019, a 2-week didactic training curriculum was designed coupled with online training. 13 anesthesiology physicians and students from OGH consented to be part of the study as trainees in 2019 (wave 1) and 9 were retained in 2023 (wave 2). The longitudinal study was conducted via pre-post assessments and Kirkpatrick assessments in 2019 and 2023.

Descriptive statistics are reported in Table 1. To estimate the impact of the intervention on participants’ learning and behavior, a one-way repeated measures analysis of variance (ANOVA) was conducted to estimate the impact of the intervention (Table 2). We found there was a significant positive change in participants’ knowledge and clinical scores from 2019 through 2023.

Beyond wave one there is a sustainable multi-site positive impact after four years and thus the GRACE intervention can be successfully implemented globally. Based on these conclusions, this valid framework can be absorbed at multiple settings over a longitudinal period into routine practice.

Carotid endarterectomy is the mainstay of treatment for symptomatic carotid artery stenosis. Perioperative management of such patients is challenging(1). Anesthetic management involves decreasing diastolic time and thus regurgitant volume, as well as reducing afterload and aortic-ventricular gradient. We report a successful case of a patient with severe aortic insufficiency who underwent carotid endarterectomy under locoregional anesthesia.

A 73-year-old man, ASA IV, with severe aortic insufficiency waiting for cardiac surgery, complained of episodic amaurosis fugax. Carotid doppler ultrasound demonstrated >90% stenosis of the right internal carotid artery. Carotid endarterectomy was proposed. On preoperative study, the echocardiogram showed severe aortic insufficiency with preserved global biventricular systolic function. After informed consent and anesthetic monitoring, 1 mg of midazolam and 50 micrograms of fentanyl were administered before the anesthetic blockade. An ultrasound-guided intermediate cervical plexus block with 15 ml of 0,75% ropivacaine was performed (figure 1). Another bolus of midazolam and fentanyl were readministered within 30 minutes of the first administration and again near the end of surgery. The patient remained hemodynamically stable and the procedure (figure 2) was uneventful. After surgery, the patient was transferred to a level 2 intensive care unit.

For carotid endarterectomy some studies describe better intraoperative hemodynamic stability as well as enhanced control of postoperative pain using a locoregional technique (2). In our case, the execution of an intermediate cervical plexus block allowed for real-time intra-operative neurological monitoring in an awake patient and less cardiovascular impact on a high-risk cardiac patient while giving optimal anaesthetic effect for surgical purposes.

A 75 year old male presented to hospital with traumatic injuries after falling down stairs. He sustained multiple rib fractures, facial fractures and bilateral displaced radial fractures. The patient developed pulmonary contusions and rib fracture pain was managed with multimodal analgesia including an erector spinae plane catheter. He was listed for bilateral distal radial open reduction and internal fixation (ORIF) by trauma surgical team.

Bilateral infraclavicular brachial plexus block performed whilst patient awake in supine position using an 80mm needle in plane with real time ultrasound. Total of 40 ml of 0.375% Bupivacaine used. Sedation was achieved with Propofol target controlled infusion and boluses of midazolam and ketamine. No airway intervention was required, the patient breathed spontaneously throughout.

Right and left distal radial ORIF were performed simultaneously with separate surgical teams with pneumatic tourniquets on each arm.

In our experience anaesthetists would be hesitant to perform bilateral brachial plexus blocks due to concerns regarding inadvertent phrenic nerve block, local anaesthetic toxicity and perceived patient discomfort with bilateral motor block. We carefully calculated local anaesthesia doses for two blocks as well as considering the contribution of bupivacaine from the erector spinae plane catheter. Ultrasound guided infraclavicular block allowed us to reduce risk of phrenic nerve embarrassment and perform the block comfortably in a supine position with minimal patient movement. In this case regional anaesthesia avoided the perioperative risks of a general anaesthesia in a patient with significant chest trauma, the patient recovered well post-operatively.

Erector Spinae Plane Block (ESPB) is a safe and effective analgesic alternative to epidural in patients with coagulation disorders. It was first applied in the paediatric population for postoperative pain management in 2017. It is particularly beneficial in the context of enhanced recovery following surgery protocols and multimodal analgesia. Single-shot or continuous infusion techniques have been previously described, and non-inferiority has been observed when compared with other locoregional techniques.

A 10-year-old boy, weighing 38kg, ASA III, with chemotherapy induced pancytopenia, was scheduled for elective excision of Ewing’s sarcoma of the 7th, 8th and 9th ribs. Following parental consent, general anaesthesia was combined with a continuous ipsilateral ESPB, performed under ultrasound guidance at T7 level. A bolus of 19mL 0.2% ropivacaine was administered. Perioperative analgesia was completed with lidocaine (1mg/Kg), ketamine (0.3mg/kg). At the end of surgery, acetaminophen (15mg/Kg) and morphine(0.1mg/Kg) were administered. Postoperative infusion with 0.2% ropivacaine (7ml/h) was combined with 3ml boluses 3 times a day, fix acetaminophen/tramadol and ketorolac SOS.

During surgery the patient remained hemodynamically stable. Postoperative pain VAS remained low (0-1), and no rescue analgesia was needed. The catheter was removed on day 7 with extreme patient satisfaction.

In this case report we demonstrate that continuous ESPB provides safe and effective pain management, as part of multimodal analgesia for thoracic open surgery in a paediatric patient with pancytopenia. Therefore, ESPB may be considered to be an effective alternative to epidural block in children, even more so in cases of contraindication to the neuraxial approach.

Pathological fractures in cancer patients cause severe pain that is difficult to control pharmacologically. Continuous regional nerve blocks play a definite role in controlling such pain. Continuous Femoral Nerve Block (cFNB) was described a safe and effective analgesic technique for hip fractures, especially in adult patients.

A 7-year-old girl, weighing 23kg, ASA IV, with a palliative metastatic neuroblastoma and thrombocytopenia (71000 platelets) was scheduled for bilateral femoral neck fracture osteosynthesis at 2 different surgical timings, under the same anaesthesia technique. General anaesthesia was combined with ipsilateral cFNB performed under ultrasound guide, and a 9ml bolus of 0.2% ropivacaine was administered. Intraoperatively analgesia was completed with lidocaine (1mg/Kg), ketamine (0.3mg/Kg). Postoperatively a perfusion of 0.1% ropivacaine at 5ml/h was initiated and maintained until day 4 postoperative combined with acetaminophen (15ml/Kg) every 6 hours.

Surgery and anaesthesia were uneventful. In the postoperative period leading to hospital discharge (5 days later), the VAS at rest or movement remained low (0-1), and no rescue analgesia was needed. The child showed an extreme degree of satisfaction with the management of postoperative pain, and no complications with the cFNB were reported during the hospital stay.

In the present case report, a Continuous FNB was found to be a safe and effective analgesic technique for the management of pain associated with pathological fractures in paediatric cancer patient with thrombocytopenia. Consequently, cFNB should also be considered for these patients also preoperatively, to ensure adequate pain management and improved overall patient experience.

In thoracic trauma with pneumothorax, mechanical ventilation should be avoided whenever possible. Regional anesthesia can be an attractive alternative anesthetic approach in this setting. In clavicular surgery, regional anesthesia requires the block of various nerves that conduct nociceptive information of the skin over the incision area and the clavicula periosteum.

A 66 year-old male patient was scheduled for open reduction and internal fixation of the right clavicle. He had a closed, displaced fracture in the middle third shaft of the right clavicle (car crash). The pre-anesthetic patient assessment revealed a significant medical past: ischemic stroke in 2016 and controlled arterial hypertension. The patient also presented a small right hemopneumothorax and bilateral rib fractures. The anesthesia plan included a regional anesthesia combined with dexmedetomidine perfusion. The regional anesthesia of the surgical field was achieved with a superficial cervical plexus block, combined with a clavipectoral fascial plane block.

The surgery lasted 2 hours, during which the patient remained comfortable, with total sensory block. Towards the end of the surgery, acetaminophen and parecoxib were administered. In the post-anesthesia care unit, the patient complained of no pain and no rescue analgesia was needed. During the first 24h post-surgery, the pain remained controlled with conventional intravenous analgesia with acetaminophen and non-steroidal anti-inflammatory drugs.

In our case report, we decided to combine clavipectoral fascial plane block and superficial cervical plexus block. Together, these blocks can provide complete sensory anesthesia for surgical procedures involving the clavicle, providing a safe and reliable alternative to general anesthesia.

Accurate monitoring of the needle tip position during a nerve block procedure enables the procedure to be performed effectively and safely. Electrical impedance (EI) values, which indicate the electrical resistance of the needle tip, can be measured by using a nerve stimulator. The EI values vary depending on the water retention of the tissue at the needle tip. We report changes in the EI values in three patients in whom EI values were measured at multiple points during a popliteal sciatic nerve block.

We obtained written case report consent from three adult patients undergoing elective lower extremity surgery. All of the blocks were performed before induction of general anesthesia. EI values were recorded when the block needle tip was within the biceps femoris muscle (#1), just outside the paraneural sheath (#2), inside the paraneural sheath (#3) on the ultrasound monitor, and after a local anesthetic had been administered within the paraneural sheath (#4).

The 4-point EI values (kΩ; #1, #2, #3, #4) for the three patients were (8.3, 8.3, 14.3, 5.9), (6.5, 7.3, 10.1, 5.2), and (6.5, 9.0, 12, 3.0) respectively. In all cases, the EI values increased when the needle tip entered from the outside to inside the paraneural sheath, and the EI values significantly decreased after local anesthetic administration. No adverse events occurred.

The results suggested that monitoring changes in the EI value during a popliteal sciatic nerve block may be a new indicator of the needle tip location.

The clavipectoral fascial plane block (CPB) is a recent regional anesthesia technique that has been utilized for clavicular fracture surgery. Although the sensory innervation of the clavicle is controversial, CPB seems to be effective since many of the sensory nerves pass through the plane between the clavipectoral fascia and the clavicle itself. We describe 3 cases where general anesthesia and airway manipulation were avoided with the use of CPB as sole anesthetic technique.

We present 3 patients with closed, complete midshaft fractures of the clavicle, submitted to open reduction and fixation. The first case was a 74-year-old patient with history of heart failure (Ejection fraction <20%). We performed a CPB with 20 mL ropivacaine 0,5% and minor sedation with midazolam. The second case was a 19-year-old patient victim of trauma with multiple rib fractures and pneumothorax. We did a CPB with 30 mL ropivacaine 0,5% under sedation with 0,5-0,7 mcg/kg/h of dexmedetomidine. The third case was a 54-year-old patient with history of difficult airway. We used CPB with 30 mL ropivacaine 0,5% combined with dexmedetomidine sedation.

In all cases, there were no registered complications and pain scores were low (VAS score of 1-2/10) in PACU.

This technique may provide benefits to patients with difficult airways and in trauma. Comparing with interscalene block, CPB can avoid adverse events such as ipsilateral phrenic nerve palsy, vocal cord paralysis, vertebral artery injection, total spinal anesthesia and pneumothorax. However, loss of the fascia’s integrity during trauma may compromise the spread of the local anesthesia.

General anesthesia (GA) has been the anesthetic choice for clavicle surgery (CS) since regional techniques can be particularly challenging. Interscalene brachial plexus block (ISC) combined with superficial cervical plexus block (SCP) has been successfully performed, but not without risks. Recently, the clavipectoral plane block (CPB) was described as an injection of local anesthetic (LA) under the clavipectoral fascia. CPB avoids potential side effects related with ISC such as motor block of the upper limb (UL), phrenic nerve palsy, Horner’s syndrome, vertebral artery injection and total spine anesthesia.

A 48-year-old male, ASA I with complete displaced fracture on the lateral third shaft of the clavicle, was purposed for an open fixation with a plate and screws. The patient had four rib fractures on the ipsilateral side with mild respiratory impairment. An ultrasound guided SCP and CPB (3 injections on the 3 points above the clavicle) were performed, with a total of 40 mL of LA (20 mL ropivacaine 0,5% and 19 mL lidocaine 1,5%), under sedation (1 mg midazolam, 50 ug fentanyl).

The patient remained comfortable and stable throughout the surgery, under propofol (4 mg/kg/h).

The combination of CPB and SCP is a safe and useful technique for CS. The prevention of phrenic nerve block and pneumothorax remain the two advantages in this case report. Moreover, it allows preservation of motor function of the UL and avoidance of GA. It remains unclear if this block maintains his success profile in case of ruptured clavipectoral fascia.

Clavicle fractures are a pathology with a relatively low incidence (2-3% of all fractures). 
Only a percentage of cases require surgical treatment. Among the different anaesthetic approaches, general anaesthesia associated with locoregional techniques is generally the gold standard. Classically, the regional block of choice has been the interscalene block.
 However, the development of ultrasound-guided peripheral blocks allows more interesting analgesic options, such as the clavipectoral fascia block described by anaesthesiologist Dr Luis Valdés in 2017.

About 10 cases of clavicle fractures. Patients aged between 28 and 42 years, ASA I except for one ASA II patient due to type I obesity.
 All cases were scheduled surgeries for open osteosynthesis for acromioclavicular fracture-dislocation.
 Balanced general anaesthesia combined with CPB block at the mid-clavicular level along with ultrasound-guided superficial cervical plexus block was performed under standard monitoring and standard premedication.

No adverse effects or anaesthetic complications were reported. The dose administered was 15 ml bupivacaine 0.5% for CPB and 5 ml bupivacaine 0.5% for the superficial cervical plexus block.
There was no evidence of motor block of the operated limb. Immediate postoperative VAS was 0 in all cases and no rescue analgesia was required in the first 24 hours, only the usual multimodal analgesia.

CPB associated with superficial cervical plexus block is an effective analgesic alternative for clavicular surgery. It is a safe ultrasound-guided block, which makes it a valid alternative to multimodal intravenous analgesia. Further studies are needed to demonstrate the efficacy, advantages and complications associated with this locoregional technique.

Interscalene brachial plexus block, alone or in combination with general or intravenous anesthesia, is commonly used in shoulder surgery. It provides adequate postoperative analgesia and reduces opioid consumption. Supraclavicular block is used for distal upper arm, elbow and forearm surgery. We present a case of a patient undergoing shoulder and elbow surgery in combined peripheral nerve blocks and i.v. anesthesia, with intraoperative change of a patient position from a lawn chair to prone.

A 77-year-old female patient, ASA II, was scheduled for surgical repair of a left proximal humerus and proximal forearm fracture. An ultrasound-guided interscalene block was performed with 20 mL of 0.75% ropivacaine, and the patient was placed in the lawn chair position. After shoulder arthroplasty, an ultrasound-guided supraclavicular block was performed with 10 mL of 0.75% ropivacaine, and the patient was placed in the prone position. During the operation, the patient was sedated with propofol, with target control infusion in the Marsh mode at a concentration of 0.4 to 0.8 mcg/mL.

Verbal rating score for pain was obtained in the recovery room, 0/10 (no pain/worst imaginable pain), and after six hours, 4/10. Analgesics were prescribed to prevent rebound pain.

When performing surgery with patients in the prone position, anesthetists would most often prefer general anesthesia with peripheral nerve block for analgesia where appropriate. Combined peripheral nerve blocks with i.v. sedation may be considered as a safe anesthetic option in operations with the intraoperative change of patient’s position.

Brugada Syndrome (BrS), a rare congenital disorder affecting cardiac sodium channels, poses significant risks during anesthesia. Patients are susceptible to sudden cardiac death, ventricular arrhythmias, and may be sensitive to certain anesthetic agents. Close cardiac monitoring is crucial to ensure their safety. Adequate pain control is mandatory, because pain and stress during surgery can increase sympathetic activity which can trigger arrythmias.

A 19-year-old male, ASA ll clinical status, with BrS was proposed for a proximal humerus fracture repair. The patient was proposed for combined anesthesia with standard ASA+BIS monitoring.Defibrillator was prepared in the operating room, and the pads were attached to the patient. The patient underwent interscalene brachial plexus block with a perineural catheter placement, combined with general anesthesia. The ultra-sound guided technique was performed with the patient awake and 10ml of levobupivacaine 0.25% were administered through the catheter, after which general anesthesia was induced with propofol, fentanyl and rocuronium and maintained with sevoflurane.

During the perioperative period, the patient was hemodinamically stable with normal sinus rhythm and no ST segment changes. A 0.2% ropivacaine perfusion through the perineural catheter was started postoperatively, for pain control. The patient was discharged 36 hours after surgery without any complications, and a great pain control.

The combined anesthesia provided intraoperative hemodynamic stability. Additionally, an opioid-sparing analgesia reduced the postoperative nausea and vomiting risk, thus avoiding the need for drugs that could increase the risk of arrhythmia in this patient. Therefore, this approach is important in patients with Brugada Syndrome, ultimately improving patient outcomes.

In breast surgery, locoregional anesthesia has shown its effectiveness in pain management and in preventing the onset of post-mastectomy pain syndrome (PMPS). In particular, a totally opioid-free approach can be reserved for fragile patients. We experienced a series of ESP block and parasternal (PSB) block combination as a new approach for analgesia in modified radical mastectomy (MRM).

We selected five patients from 34 to 68 years old who underwent a modified radical mastectomy; ESP block was performed at T5 level with 25 ml of ropivacaine 0,5 % and PSB block was administered with 10 ml of ropivacaine 0,5% between II and IV ribs for a better cover of the anteromedial wall chest. Patients underwent general anesthesia with a supraglottic device and opiods were given neither during or after surgery. Intravenous Paracetamol was provided every 8 hrs for 24 hrs.

Pain score in a NRS scale, mgs of morphine demanded by patients and presence of PONV were recorded. Four of five patients reported a pain score <3 on the NRS scale, only 1 patient required 1 mg of morphine at 6 hrs with a score of 5 on NRS scale. No other symptoms were described. Furthermore, at a three-month post-operative follow-up, no pain >2 on the NRS scale was reported.

Combination of ESP block + PSB block has shown efficacy in ensuring good pain management during and after MRM in a totally opioid-free anesthesia perspective. Moreover, the low onset of pain at three months suggests its potential in PMPS prevention.

Lumbar disc herniation is the most common degenerative disease of the lumbar spine. It is also the most common reason for lumbar spine surgery. Although disc herniation is more common in the fourth and fifth decades, it can be seen in all age groups. Lumbalgia is the most common initial symptom of this degenerative disease with a wide clinical presentation. It is known that failure to manage pain effectively in the postoperative period can cause chronic pain.

Visual analog scale(VAS) scores were noted in the first postoperative period, at the 15th minute, at the 4th hour and at the 12th hour in patients who were operated for lumbar disc herniation and underwent one of the modified thoracolumbar interfascial plane(m-TLIP) and erector spinae plane(ESP) blocks.

There was no statistically significant difference in the VAS score of m-TLIP and lumbar ESP blocks in postoperative analgesia of lumbar disc herniation repair surgery.

The m-TLIP block was defined in 2017 as an alternative to TLIP block, and is a block that has been used in recent years to effectively provide postoperative analgesia in LDH surgery (1). Technically, it is performed by administering a local anesthetic solution to the fascia between the longissimus and iliocostalis muscles in the lumbar region. A block is performed by administering local anesthetic between the transverse process of the vertebra and the fascia of the erector spinae muscle. In order to provide postoperative analgesia of LDH surgery, ESP and m-TLIP blocks are alternative methods within the scope of multimodal analgesia.

The Erector Spinae Plane (ESP) block is paraspinal fascial plane block that targets both ventral and dorsal rami of the thoracic and abdominal spinal nerves. It has been used to provide analgesia for a range of surgical procedures and painful conditions. Spontaneous cough-induced rib fractures are a rare but recognised phenomenon in term parturients. Patients who experience rib fractures near term often undergo elective caesarean delivery, due to the recognition that thoracic pain may limit patient effort in the second stage of labour. We present a case of ESP catheter managed rib fracture pain, facilitating labour and vaginal delivery in a term parturient with a cough-induced rib fracture.

A 38-year-old woman, para 1, presented at 37+6 weeks gestation with left-sided pleuritic chest pain, following a lower respiratory tract infection, which was associated with intense bouts of coughing. The presumptive diagnosis was an atraumatic rib fracture and she was initially discharged with analgesia. She re-presented the following day with 10/10 pain despite paracetamol, oxycodone and a lidocaine patch. A mid-thoracic ESP catheter was inserted under ultrasound guidance with immediate relief. She received 4-hourly clinician administered boluses of 20ml of 0.125% levobupivacaine for 5 days with a maximum pain score of 4 on coughing.

With adequate analgesia attained and following multi-disciplinary input, she underwent induction of labour, resulting in an instrumental vaginal delivery undercombined ESP and epidural analgesia.

ESP blocks could be considered for pregnant patients presenting with rib fracture pain near term, who wish to attempt labour and vaginal delivery.

Erector spinae plane (ESP) block is an interfascial plane block. There are reports in patients undergoing spinal, breast, thoracic and abdominal surgeries with some conflicting results.

A 22 year old healthy woman suffered a penetrating trauma between the chest and armpit with a wooden stick. An uneventfully general anaesthesia was performed to remove it and she went to the ward with continuous intravenous analgesia with drug infusion balloon (DIB). After surgery patient was conscious reporting severe pain and paresthesia in the median nerve territory despite multimodal analgesia. On the second postoperative day the intravenous infusion was stopped because nausea and vomiting. The pain, located mainly in the axilla, was controlled at rest but severe when moving, preventing rehabilitation therapy. It was performed an ultrasound-guided continuous ESP block at T4 level and 20 mL 0.2% Ropivacaine was injected. 8 mg intravenous dexamethasone was administered. There were no intercurrences and the patient reported great relief of pain. A perineural infusion of 5 mL/h 0.2% Ropivacaine was started. On the next days it was possible to do rehabilitation therapy and pain on mobilization progressively improved. On the seventh postoperative day the infusion was stopped because pain control was found at rest and in movement, without rescue analgesia.

The mechanism of action of the ESP block is a matter of debate. It was evident that the bolus contributed significantly to pain control when it was administered and the continuous block facilitated the rehabilitation therapy.

Continuous peripheral nerve block (CPNB) is an effective technique for acute pain control with a low incidence of serious adverse events. However, failure is a recognised complication and not uncommon. This audit aims to establish the incidence of primary (inadequate insertion) and secondary failure (catheter displacement, disconnection, occlusion, leakage) at our institution.

All patients receiving CPNB over a 3-month period (August to October 2022) at St George’s Hospital, UK, were identified. Information on their management was collected retrospectively from their electronic hospital records.

120 episodes of CPNB in 103 patients were analysed. 65% (n=77) were chest wall catheters: 32% (n=38) paravertebral (PV); 21% (n=25) erector spinae plane (ESP) and 12% (n=14) serratus anterior plane (SAP). 27% (n=32) were sciatic. The remaining 10% (n=11) included intrapleural, femoral, rectus sheath and transversus abdominal plane (TAP) catheters. Mean catheter duration was 3.9 ± 2.3 days. Overall, 67% (n=80) remained until no longer clinically needed. However, 30% (n=36) were removed for other reasons. The majority of these, 75% (n=27), suffered problems of displacement, disconnection, occlusion or leakage (i.e. secondary failure). 14% (n=5) were removed for not being effective (primary failure); 6% (n=2) because of infection and 6% (n=2) for other reasons.

The overall incidence of secondary, and potentially preventable, CPNB failure in our institution is 23% (n=27), which results in a significant burden of work for the treating clinicians and sub-optimal pain management for these patients. This is prompting renewed scrutiny of our processes, especially regarding the ongoing management of CPNB.

Continuous peripheral nerve blocks remain the minority technique included in ERAS protocols to decrease opioid requirements. One common deterrent to the placement of continuous modalities are cost and questionable longevity of these blocks due to leaking and migration. The current literature is lacking in the incidence of leaking especially among obese patient populations. One prevailing thought is the method in which these catheters are placed is flawed: by inserting the catheter through the needle, the diameter differences between the catheter and puncture site contributes to its leaking versus over the needle. The aim of this study is to evaluate the rate of leaking without BMI restrictions comparing over the needle to through the needle catheters in highly mobile lower extremity blocks.

Retrospective chart review of 79 patients that received a continuous popliteal nerve block without exclusions to BMI utilizing either the Pajunk-E cath echogenic the over the needle (CON) or Halyard T-Block continuous echogenic through the needle(CTN) techniques as part of their ERAS care.

Subjects that received CON catheters experienced a reduced rate (average 11.1%) of leaking as compared to the CTN group with (38.46%) with a p-value of 0.018. The impact of BMI resulted with a higher rate of leaking in the CTN of 80% and CON had 14.3% with a p-value of 0.015.

The reduction of leaking noted lower extremity continuous peripheral nerve blocks in obese patients can be reduced by utilizing an over the needle system. This prolongation could prevent opioid related complications and enhance rehabilitation.

The number of elderly patients presenting for trauma surgery is increasing with the aging population. The perioperative management of the elderly is often complicated by coexisting diseases and polypharmacy which may delay surgical treatment due to preoperative optimization. The anesthetic technique should be guided by the intended surgical procedure, patient preference and comorbidity. Frail elderly patients are at increased risk for postoperative complications, cognitive impairment, and longer hospital stays.

A 95-years old female had unstable fracture after external fixation of tibia and fibula, due to trans calcaneal pin instability. She was scheduled for replacement of external delta frame fixator with supracutenous locking plate but had an ischemic stroke six days after the first surgery. Six weeks after the stroke and partial recovery of left-sided hemiparesis, the extraction of delta frame and supracutenous plate fixation has been performed in ultrasound-guided popliteal nerve block combined with a saphenous nerve block, with 0.75% ropivacaine.

A small dose of ketamine, 15 milligrams, was administered during the surgical procedure in the peripheral nerve block as the patient indicated slight pain at the skin incision. Neither extra sedation nor analgesics were required during the surgery nor for ten hours following. The patient was pleased with the painless treatment and showed no signs of cognitive impairment, enabling safe discharge the following day. The patient is routinely going to surgical check-ups six months following the surgery.

Peripheral nerve block should be considered where feasible in the primary approach to anesthesia and analgesia in the elderly patient.

Peripheral nerve blocks achieve optimal conditions for ambulatory surgery. Pain catastrophizing, a psychological negative attitude towards the pain experience, is associated with higher postoperative pain (1) including higher risk of rebound pain (RP) (2). Intravenous dexamethasone (DEXA) potentiates nerve block analgesia and reduces RP incidence (3). The study evaluated the effects of DEXA on RP in ambulatory patients according to their preoperative catastrophizing status.

Retrospective secondary analysis of data evaluating intraoperative DEXA (4-10 mg) in ambulatory patients undergoing upper limb surgery under axillary plexus block. Perioperative analgesic regimen was standardized. Preoperative catastrophizing score (0-52), postoperative pain at block dissipation, mean and maximum pain on day 1, were recorded. For data analysis, patients with or without intraoperative DEXA were classified as low (LPC) or high pain catastrophizers (HPC, catastrophizing score > 75th percentile). Ethics committee approval has been granted.

Data of 228 adult patients were available (45% men, age 50±15, BMI 25±6). Average catastrophizing score was 12 (IQR 3-23). In HPC group (n=58) and LPC group (n=170), respectively 53% and 23% had RP (p<0.001), 48% and 53% received DEXA (p=0.547). Postoperative data are in the table hereunder.

Intraoperative antiemetic (low) dose of DEXA only reduced pain at block dissipation and RP occurrence in LPC. Low DEXA dose however reduced average day 1 pain in both HPC and LPC. Higher intraoperative DEXA dose or repeated DEXA dose in HPC deserve further studies to better personalize perioperative pain management in high pain responders’ population (1).

Scoliosis surgery is painful and requires high doses of intravenous opioids. We present a case report where regional analgesic techniques significantly reduced postoperative opioid needs

19yr old idiopathic scoliosis patient presented for a posterior instrumentated fusion T2 to L1. Awake spinal at L34 was done with 0.3mg morphine in 3 ml saline. Propofol, Remifentanil,dexmedetomidine TIVA was administered guided by BIS. After induction bilateral US guided ESP blocks were done at T4 and T12 with 40 ml 0.125% Bupivacaine. Paracetamol, parecoxib and 4 intermittent doses of 0.25 mg/kg ketamine were given intraop. No long acting opioids or surgical local infiltration was used. At the end of surgery, bilateral mulitiorifice ESP catheters were placed lateral to the rods by the surgeons. This was topped up with 40 ml 0.25% Bupivacaine at the end of surgery.

On awakening patient required no opioids and remained comfortable on regular paracetamol, ibuprofen, nefopam and dexamethasone. He mobilised independently at 15hrs and was discharged by the physiotherapist on day 2 and went home day3. During his stay the only breakthrough pain requirement was 2 dose of 10 mg oromorph. Minimal nausea and no ileus was noted postop.

Traditional approach to scoliosis involves very little use of regional analgesia. While intrathecal morphine provides excellent analgesia in the first 24hrs, patients need strong opioids over the next few days. These opioids often have significant side effects. We have demonstrated the huge analgesic benefit of surgically placed ESP catheters in this surgical population with a reduction in GI side effects

The ESP block is an interfascial plane block first described in 2016 in the management of thoracic neuropathic pain. Since then, it has found use as an analgesic option in various settings including cardiac and spine surgeries. In this case series, we describe the application of an ESP block in two patients undergoing endoscopic retroperitoneal adrenalectomy.

We conducted these ESP blocks as part of multimodal analgesia in conjunction with general anaesthesia. 25mls of 0.5% Ropivacaine was administered for both cases in the erector spinae plane in conjunction with general anaesthesia. This was conducted at the level of the T9 Transverse Process in Patient 1 and T12 Transverse Process in Patient 2.

The use of an ESP block provided satisfactory analgesia with a reported NPRS of 5 out of 10 with 90% satisfaction for our first patient on POD 1. Additionally, our second patient reported no pain at rest and mild pain on movement with 90% satisfaction for pain relief on POD 1. Both patients required 5mg of oxycodone cumulatively in the intra and post-operative period. Both patients required no additional opioids on the general ward and were discharged on POD1.

The use of ESP blockade can be considered as an analgesic option in conjunction with multimodal analgesia for endoscopic retroperitoneal adrenalectomy surgery. This potentially allows for decreased opioid usage and reduction of its associated side effects. The use of such a technique to decrease incidence of chronic post-surgical pain (CPSP) in these patients remains to be studied.

Rib fractures are common in trauma patients and require effective analgesia to prevent respiratory complications. Regional anaesthetic techniques, such as thoracic epidural or paravertebral block, are often the mainstay of treatment. In the erector spinae plane (ESP) block, by placing the local anesthetic deep to the erector spinae muscle and near the costotransverse foramina, we can achieve effective analgesia.

We report a case of a successful ESP block using a continuous technique for analgesia in a 60-year-old trauma patient who presented with multiple left-sided rib fractures from T3-T8. 24 hours post injury the patient complained of severe pain in the left hemithorax and was unable to take a deep breath or cough, despite optimized intravenous analgesia. With the patient in a right lateral decubitus position, a left-sided ultrasound-guided ESP block was conducted at the level of T6. A bolus of 30ml 0,2% ropivacaine produced almost immediate pain relief. An indwelling peripheral nerve block catheter was placed within the ESP under ultrasound guidance. The catheter was secured in place. A continuous infusion of 10 ml/h 0,2% ropivacaine with patient-controlled analgesia boluses of 5mL was initiated.

In the following days, the patient revealed lower pain scores and greater breathing ability. After 3 days the catheter was removed.

Fascial plane blocks like the ESP block are technically easier to perform compared with neuraxial and targeted nerve blocks and have fewer serious side-effects. In our case, the presence of unilateral rib fractures made the ESP block an effective alternative to neuraxial or paravertebral procedures.

We present the anaesthetic management of a severely frail patient who underwent urgent exploratory midline laparotomy under bilateral erector spinae plane block (ESPB) and “Ketodex” sedoanalgesia. ESPB can result in both visceral and somatic abdominal analgesia. Literature narrows ESPB to multimodal analgesia. However, some cases of ESPB as primary anaesthetic in abdominal surgery have been reported.

A severely frail 87 yo women underwent inguinal hernioplasty with small bowel resection. At day 6, anastomosis dehiscence was suspected, and urgent exploratory midline laparotomy ensued. General anaesthesia was not considered ideal due to poor physical status and expected difficult ventilatory weaning. Neuraxial anaesthesia was not considered due to coagulopathy and thrombocytopenia. We proceeded with a bilateral ESPB injecting 30 mL of 0,5% Mepivacaine + 0,5% Ropivacaine deep to the erector spinae muscle in each side, at T9 level. We associated sedoanalgesia with bolus doses of a Ketamine and Dexmedetomidine mixture as needed, taking advantage of the opioid-free analgesia.

No anastomotic dehiscence was confirmed intraoperatively, and conversion to general anaesthesia was not needed. The patient maintained haemodynamic stability and spontaneous ventilation. Pain or discomfort was not reported during the procedure and no adverse events were recorded perioperatively.

ESPB is a feasible alternative anaesthetic technique for abdominal surgery in frail and severely ill patients, as demonstrated in this case. The synergic combination of dexmedetomidine and ketamine provides effective sedation and potentiates analgesia with a safe respiratory and hemodynamic profile.

The recently described external oblique intercostal (EOI) plane block might be a good alternative to neuraxial analgesia for upper abdominal incisions, since it is a superficial nerve block that can be performed in the supine position and has easily identifiable ultrasound points, providing upper midline and lateral abdominal wall analgesia.

A 57-year-old female patient, ASA-PS III, presenting with left emphysematous pyelonephritis, was submitted to urgent left total nephrectomy through an oblique subcostal incision. The surgery was performed under general anaesthesia combined with an ultrasound-guided injection of 20 mL of levobupivacaine 0.25% (50mg) and dexamethasone 4mg in the EOI fascial plane. Multimodal Intravenous analgesia with paracetamol 1g and tramadol 100mg were also administrated.

Before emergence from anaesthesia, a catheter in the EOI plane was placed and 20mL of ropivacaine 0.2% (40mg) was given. Upon awakening, the patient reported no pain. The postoperative pain management regimen involved intravenous paracetamol 1g every 8 hours and 20ml of ropivacaine 0.2% (40mg) through the EOI plane catheter every 4 hours. No additional analgesia was required.

The EOI plane block shows promising results in targeting upper abdominal wall analgesia, an anatomic region not sufficiently addressed by other fascial plane blocks, such as the subcostal Transversus Abdominis Plane block or the Rectus Sheath block.

Effective postoperative pain management is challenging after open hepatobiliary surgery. Our trust increasingly uses spinal anaesthesia with regional techniques such as preperitoneal wound catheters (inserted by the surgeon prior to wound closure) and external oblique intercostal (EOI) blocks. The EOI is a novel block to deposit local anaesthetic in the fascial plane between the intercostal and external oblique muscles at sixth rib level. Case studies and cadaveric work offer positive evidence basis. We aim to evaluate the efficacy of both techniques.

We collected retrospective data from consecutive HPB surgery patients who received spinal anaesthesia and either EOI block catheters or wound catheters. Data collected included pain scores, PCA requirements, time in HDU, length of stay, and time to bowel function and soft diet initiation.

Patients reported mild to moderate postoperative pain suggesting that both techniques, as part of multi-modal analgesia, are effective. EOI blocks may be a superior technique to wound catheters as patients who received EOI blocks had shorter stays in HDU, were discharged earlier, and reported lower pain scores. They also had earlier removal of PCAs, mobilisation, return of bowel function, and initiation of soft diet.

Our study highlights the importance of evaluating and optimising postoperative pain management techniques ensuring patients receive the best possible care. The use of both preperitoneal wound catheters and EOI blocks, in combination with spinal anaesthesia, appear to provide effective analgesia these patients. Further work is needed to confirm the superiority of EOI blocks over wound catheters.

Although there is no gold standard regimen yet on regional or multimodal pain management for hip patients, some ultrasound-guided peripheral nerve blocks such as the fascia iliaca (FI) and lumbar plexus (LP) blocks were known to provide good analgesia, and to compare the effectiveness and safety of these two was the aim of this study.

This was a retrospective, cohort type of study done through chart review of hip surgery patients at a tertiary care center. The primary endpoint was patient reported pain scores using numeric rating scale (NRS) at post-anesthesia care unit (PACU) and within 24 hours post-block.

From the 50 patients who underwent hip surgery, 36 and 14 patients were given ultrasound-guided FI and LP blocks, respectively. The clinical outcomes such as post-operative pain, length of stay at the PACU, and adverse events were comparable (p> 0.05) between the two groups. Overall, the post-operative pain score was graded as zero by the majority of patients at zero minutes up to 120 minutes, 92% and 88% respectively. A pain score of 6 to 10 (severe pain) was noted by 1 to 2 patients up to 60 minutes post-operative. There were no adverse events reported, and PACU stay was at a median of 2 hours, shortest was at 2 hours and longest was at 5 hours, which was noted in the FI group.

Fascia iliaca and lumbar plexus blocks were both effective and safe in providing post-operative pain control in hip surgery patients.

This clinical case reports the effectiveness of the greater occipital nerve block (GON-block) in controlling postoperative pain in an 85-year-old man who underwent excision of a basal cell carcinoma in the occipital region and reconstruction with a bilobed flap. The GON block is performed by injecting local anesthetic close to the greater occipital nerve and it can be performed relatively quickly, simply and effectively. The available literature describes the efficacy of this block in the relief of cervicogenic headache, occipital neuralgia and migraine. However, evidence of its analgesic effectiveness in surgeries of the scalp of the occipital region is scarce.

85-year-old man, physical status ASA II. For the aforementioned surgery, he underwent combined anesthesia (balanced general anesthesia and GON blockade with 4 ml of Ropivacaine 7.5mg/ml, guided by ultrassound), with no surgical or anesthetic complications to be recorded. Postoperatively, we opted for a multimodal analgesia strategy with Paracetamol 1000mg IV 8/8h and Tramadol 100 mg IV as needed (maximum 8/8h). Pain intensity was evaluated using the numeric pain scale at 3, 5, 8, 12 and 24 hours.

In every evaluation the patient reported pain ≤ 1. Tramadol administration was never necessary.

This clinical case suggests the effectiveness of this block in controlling postoperative pain in a patient who underwent surgery for the scalp in the occipital region. We also highlight the blockade’s apparent opioid-sparing effect. Further studies are required in order to demonstrate this block’s full potential.

Acetabular fractures are commonly associated with severe postoperative pain, and there is currently no shared consensus regarding analgesia compared to hip fractures. The acetabulum is mainly innervated by the lumbar plexus (LP), however the posterior approach to the LP is technically difficult and associated with serious complications of spinal and epidural spread, intravascular injection with local anaesthetic systemic toxicity and retroperitoneal haemorrhage.

A 62-years-old male, ASA2, 67kg, underwent open reduction internal fixation of double column acetabular fracture. Supra-inguinal fascia iliaca (FI) compartment block was performed after induction of general anaesthesia. The ultrasound probe was positioned in a parasagittal plane inferomedial to the anterior superior iliac spine, the iliacus muscle, internal oblique and sartorius forming the bow-tie sign and the deep circumflex iliac artery were identified. Needle was introduced in-plane in caudal to cranial direction, 40ml 0.3% ropivacaine was given with hydrodissection and cranial spread of local anaesthetic deep to the fascia iliaca into the iliac fossa visualised.

In the first 48 hours postoperatively, patient reported a numerical rating scale for pain < 4. Bromage score was 0. Multimodal analgesia was initiated with paracetamol, etoricoxib, sustained-release oxycodone/naloxone and oxycodone for breakthrough pain. Patient took total 47.5mg oxycodone. Pain control was satisfactory.

High volume supra-inguinal FI block aims to improve cranial spread of local anaesthesia high in the iliac fossa to consistently block the femoral nerve, lateral femoral cutaneous nerve and obturator nerve which contribute to acetabulum innervation. It is a safe technique that provides effective postoperative analgesia in acetabular fracture surgery.

Urgent tracheostomy is needed to treat upper airway obstruction in patients with head and neck cancer. It sometimes constitute an anesthetic challenge, especially for causing obstruction and distortion of the airway’s anatomy. Bilateral intermediate cervical plexus block (BICPB) allows anesthesia of the anterior neck, allowing the performance of superficial neck surgery. This abstract aims to demonstrate the effectiveness and safety of regional anesthesia in patients undergoing urgent tracheostomy.

A 62-yeard-old man, ASA IV, with history of alcohol abuse and basaloid squamous cell carcinoma (cT3N2bM0) presented to the emergency room with stridor and worsening dyspnoea at rest. He was proposed for urgent definitive tracheostomy, in which induction of general anesthesia had a high risk of airway loss, because the mass was causing glottis obstruction with a maximum diameter of approximately 4 mm. We performed an ultrasound-guided BICPB with 4 mL ropivacaine 0,75% in each side. 100 µg of fentanyl, 1 mg midazolam and 15 mg of ketamine were administered for conscious sedation.

10 minutes after BICPB we obtained sensory block in dermatomes C2-C4. After cannulation of trachea, patient was put under general anesthesia, maintained with sevoflurane. The surgery was performed without complications and the postoperative period was uneventful and painless. He was then transferred to the reference hospital in treatment of head and neck cancer after 3 days.

BICPB is an effective alternative anesthetic approach for patients undergoing urgent tracheostomy in whom general anesthesia carries a high risk. It provides complete anesthesia and long-lasting analgesia of the anterior cervical region.

Many important anaesthetic considerations are present in patients with hypothyroidism. Patients suffering from chronic alcohol misuse can present with acute deterioration, with or without concurrent illness, and necessitating intensive care. Recovery may be complicated by alcohol withdrawal. We wanted to present a case of a chronic alcoholic female patient with hypothyroidism who had to go under emergency surgery of the distal part of the humerus.

A 63- year-old woman, a chronic alcoholic with poorly treated hypothyroidism was scheduled for emergency surgery due to comminuted fracture of the right distal humerus region. On the day of surgery her TSH level was 169,39 mIU/L. Also, she had surgery performed on the same arm and shoulder before already. Beacuse of her medical anamnesis we chose to perform an interscalene brachial plexus block with light sedation. Patient was given 50mcg of fentanyl and 3mg of midazolam and 600mg of propofol intravenously in total for surgery of three hours. For the block we used 10 ml of 0,5% Levobupivacaine, 5 ml of 2% Lidocaine and Dexamethsone 4 mg using ultrasound guidance.

The patient was breathing spontaneously the whole time. Total blood loss during surgery was 300 ml. On the ward, she was disoriented and angry in the postoperative period due to alcohol withdrawal but had no opioid requirements. In 48 hour postoperative period she was given ketoprofen 100mg and metamisol 2,5g two times on the first and second postoperative day.

Peripheral nerve blocks are preferable for emergency surgery maintaining cardiovascular stability.

The dexmedetomidine and tramadol were added as adjuvant to bupivacaine in transversus abdominis plane block (TAP).

The study was carried out with 60 ASA I-II class participants aged 20-60 years who underwent laparoscopic cholecystectomy at Van Yüzüncü Yıl University Faculty of Medicine. Participants were randomized into two groups. -Group T (Adjuvant Tramadol): 40 mL of 0.250% bupivacaine + 1.5mg/kg and a maximum of 100 mg tramadol adjuvant -Group D (Adjuvant Dexmedetomidine): 40 mL of 0.250% bupivacaine + 0.5 mcg/kg and a maximum of 50 mcg dexmedetomidine adjuvant Standard general anesthesia was applied. After intubation, bilateral subcostal TAP block was performed by the same anesthesiologist, demographic data were recorded. Intraoperative vital signs of the participants (pulse, non-invasive blood pressure and peripheral oxygen saturation measurement), additional opioid and muscle relaxant needs, and complications were recorded. Extubation was performed after standard decurarization with atropine and neostigmine. Postoperative side effects (nausea, vomiting, pruritus, shivering), postoperative additional analgesic need, and 0 hour (Modified aldrete score ≥9 time was accepted as 0 hour), 3rd hour and 6th hour Visual Analogue Scale (VAS) scores were evaluated and recorded.

There was no statistically significant difference between the groups in terms of demographic data, intraoperative opioid consumption, muscle relaxant use, postoperative analgesic effects, side effects and postoperative mobilization time. (Figure 1, Figure 2).

The dexmedetomidine as an adjuvant to bupivacaine in the bilateral subcostal TAP block will provide stable hemodynamics. It should be supported by studies with large participation.

There has been interest in investigating the optimal anesthetic method for Total Ankle Arthroplasty (TAA) to optimize perioperative outcomes. Saphenous block and sciatic nerve block are usually performed and have been extensively described. We report a case in which TAA was performed on both legs at different times. For the first surgery, a sciatic nerve block at the knee was performed for postoperative analgesia. However, for the second surgery, both a saphenous block and a sciatic nerve block were performed. The objective is to evaluate any improvement in postoperative pain control by adding a saphenous block.

We present the case of a woman who underwent Total Ankle Arthroplasty (TAA) on both legs at different times. The surgeries were performed by the same surgeon under intradural anesthesia with Hyperbaric Bupivacaine 10 mg plus Fentanyl 10 mcg, Paracetamol and metamizol as postoperative analgesia. All blocks were performed using ultrasound. We evaluated postoperative pain control using the visual analogue scale (VAS) at 1, 6, and 24 hours after surgery.

We found no differences in pain control during the postoperative period. The VAS scores were 0 out of 10 at 1 hour, 2 out of 10 at 6 and 24 hours after surgery.

Despite the absence of differences in postoperative pain control in this case, according to the results obtained by Bjørn S et al., most patients benefit from a saphenous block. We still recommend performing it due to its simplicity and minimal time consumption.

Lateral quadratus lumborum blocks (LQLB) provide good analgesia for lower abdominal procedures by targeting somatic and visceral nerves whilst avoiding complications associated with neuraxial blockade (1,2,3). Despite this, caudal epidural blockade (CEB) remains a commonly practiced paediatric technique despite potential significant complications. This review aims to assess if LQLBs are a suitable alternative to CEB, Ilioinguinal-hypogastric nerve block (II-IHNB) and transverse abdominus plane blocks (TAPB) for paediatric patients undergoing unilateral day-case orchidopexy surgery.

A retrospective case notes review was performed of all patients undergoing elective unilateral day-case orchidopexy surgery between January and September 2022 at a tertiary paediatric hospital. Parameters recorded included length of stay, anaesthetic technique and peri-operative analgesic medications.

Ninety-eight patients met the inclusion criteria. Predominant regional techniques included CEB (21%, 21), LQLB (28%, 27), TAPB (18%, 18), II-IHNB (12%, 12) and local infiltration (LI) (16%, 16). CEBs experienced a complication rate of 24% (5) compared to other regional techniques which did not have any. LQLB, TAPB, and LI were statistically safer procedures. Post operative opioids were required in 14% (3), 22% (6), 50% (6), 31% (5) and 22% (4) for those receiving CEB, LQLB, II-IHNB, TAPB and LI respectively. The difference between CEB and II-IHNB was statistically significant (p=0.044 Fishers Exact Test).

Our data suggests that LQLBs provide similar post-operative analgesia compared to CEB but with a significantly lower complication rate. We suggest therefore that LQLBs are non-inferior to CEBs although further research is required to compare clinical profiles further.

Total knee arthroplasty (TKA) is one of the most common orthopedic procedures and is associated with significant postoperative pain. We present a case report of a TKA performed exclusively on peripheral nerve block (PNB) anesthesia.

A 61 year old female, ASA IV, presented for revision of a TKA due to primary arthroplasty infection. She had a history of hypertension, morbid obesity, mitral and aortic valvuloplasty. Most recent echocardiogram showed aortic valve with severe obstruction and indication for future repair. She was hypocoagulated with warfarin (INR preoperative 1.5). The following PNB were performed under ultrasound-guidance to obtain surgical anesthesia: femoral nerve, lateral cutaneous femoral nerve, obturator nerve, sciatic nerve (popliteal), with a total of 300 mg of ropivacaine (60 mL of 0.5% ropivacaine). Before incision a perfusion of propofol for light sedation was started and tourniquet inflated. Surgery proceeded during 2,5 hours uneventful. Patient reported a high level of satisfaction in the postoperative ward. In the following days the patient remained with a good analgesic control.

The standard anesthetic technique for TKA is neuroaxial anesthesia or general anesthesia. However, there are situations where those two techniques can impose increased risks and become an anesthetic challenge. As we had an urgent surgery and patient had a high INR level neuroaxial anesthesia increased risk for complications. Additionally, her valvular disease imposed an increased risk or hemodynamic stability that could be affected by general anesthetics.

We performed an exclusive PNB anesthetic technique that was tailor-made for this patient, surgery and pain control.

Ischemic pain is the main symptom of peripheral arterial obstructive disease (PAOD) and affects the quality of life. It is hard to manage with systemic analgesics so continuous peripheral nerve block may be an effective alternative with fewer side effects.

A 47-year-old female patient with hypertension, diabetes mellitus, dislipidemia and active smoking was diagnosed with critical limb ischemia and foot ulcer as a result of thrombosis of common iliac artery. She experienced severe pain in her foot and fingers, and the acute pain unit was called in to manage her pain before the surgery. A popliteal-sciatic perineural catheter was placed and we started a patient-controlled regional analgesia (5ml/hour + boluses 5ml lockout 30 minutes), after confirming pain relief with 15ml ropivacaine 0.2%

She evolved with better control of pain, requiring less opioids and adjuvants. Following five days in the hospital, the patient was discharged home with a drug infusion balloon (DIB) of ropivacaine 0.2% 5ml/h. The DIB was changed every two days during wound dressings at hospital. Despite the catheter was accidentally exteriorized it remained in place for 14 days without signs of infection or neurologic complications.

Regional analgesia, such as continuous epidural analgesia through a catheter, has been used with good response, but with possible side effects. This cases highlights the benefits of continuous peripheral nerve block which offers the advantage of minimal adverse effects, emerges as a viable alternative that does not require the use of anticoagulants and allow the patients to take the catheter home.

Proper pain management in patients undergoing Anterolateral Tigh (ALT) flap surgery is crucial to minimize early postoperative complications. We present a case of a 58-year-old male admitted for partial pelviglossectomy, mandibulectomy and ALT of the left limb, who received both limbs a femoral nerve block due to insufficient Doppler flowmetry on the limb first chosen by the surgeons. We aim to demonstrate that a pre-emptively femoral nerve block can be part of a multimodal analgesic strategy in these patients and that a second non-planned nerve block can be safely performed if the maximum dose of local anesthetic is taken into consideration.

A total intravenous anesthesia with propofol and remifentanil was induced and a single-shot, ultrasound-guided, right and left femoral nerve blocks were performed using 15 ml of 0,75% ropivacaine on each side. A total of 30ml (225 mg) was administered - a safe dose of ropivacaine for an 80kg patient. The maintenance dose of remifentanil was low (up to less than 0,05-0,10 mcg/kg/min) and analgesia was complemented with ketorolac 30mg, paracetamol 1g and morphine 2mg.

There were no signs of local anesthetic systemic toxicity (LAST) and the patient was admitted to the post-anesthetic care unit after 10h of surgery without pain in the flap area, 0/10 (numerical rating scale pain) at rest and movement. Pain at rest was only reported more than 24h after the block.

This case enhances the importance of performing vascular Doppler signals before anesthetic nerve blocks to avoid unnecessary blocks and risk for LAST.

Non-specific costal pain, characterized by flank thoracic pain caused by entrapment of nerve branches, remains a challenge for pain management physicians. In this study, we present a series of cases where patients with flank pain achieved clinical improvement through the use of NTLL plane block(Figure 1), combining local anaesthetic and triamcinolone acetate.

Case1 28-year-old female patient with persistent pain following retro-muscular periareolar breast augmentation. Despite implant removal, the pain persisted, and physical examination, thoracic electromyography, and nerve magnetic resonance imaging showed normal results. Case2 52-year-old patient underwent mastopexy with breast implants and experienced lateral thorax pain beyond the surgical innervation area. After the NTLL block, the pain subsided but returned to lower intensity after three weeks. Pulsed radiofrequency ablation of the NTLL was subsequently performed. Case3 41-year-old patient without relevant medical history experienced sudden-onset pain in the left lateral thorax after engaging in regular paddle tennis. Pain resolution occurred after the block, allowing the patient to resume sporting activities. Case4 37-year-old patient with no significant medical history, presenting with sudden-onset diffuse tenderness in the left costal area. Complete symptom resolution was achieved following the block.

To our knowledge, this is the first case series describing neuropathic pain associated with the NTLL. It is important to note that while LACNES has been recently introduced, not all cases of thoracic wall pain can be attributed to this syndrome. Consideration of the innervation of the lateral thoracic wall and the potential contribution of the NTLL is crucial in diagnosing and managing such cases

Although regional anesthesia provides prolonged postoperative analgesia, there is no suitable method that can facilitate early reversal of the blockade until the duration of action of the local anesthetic has elapsed. A large quantity of saline is used to reverse the central neuraxial block. However, to the best of our knowledge, a few study has reported a method for reversing nerve blockade in peripheral nerve blocks.

A 75-year-old man underwent right shoulder rotator cuff repair under general anesthesia. A continuous costoclavicular block was administered for postoperative analgesia. The postoperative pain was well-controlled and the pain score was 0 on the VAS. However, he was unable to moving his arm with absent proprioception, which showed signs of complete anesthesia. Hence, we injected a small amount of saline under ultrasound guidance to confirm the pattern of spread and the absence of nerve swelling due to injection. There were no signs of needle- and catheter-induced nerve damage. Then, we decided to stop the PCA for neurological examination to rule out surgical factor. However, the patient already could move his arm and complained of pain at that time.

Unexpected reversal to normal sensory and motor function was observed within approximately 15 minutes after the injection of 15mL of saline.

In conclusion, we observed a dramatic reversal of sensory and motor nerve blockade within a short time following 0.9% saline injection after a costoclavicular block. Our findings suggest that saline injection can be used to reverse the local anesthesia induced by the costoclavicular block.

Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe postoperative pain, so effective analgesia is necessary for patient satisfaction, early discharge and functional recovery. Although the use of regional techniques is widely accepted, the choice remains controversial. We compare adductor canal block (ACB) versus femoral nerve block (FNB) in our clinical practice.

A descriptive observational retrospective study was designed and its approval by IRB was requested (IIBSP-LCA-2023-67). We included 32 patients that underwent ambulatory ACLR between 2021 and 2022 at our hospital. Anaesthetic techniques, time to discharge and postoperative pain (NPRS) were collected.

The most used anaesthetic technique was spinal anaesthesia combined with ACB (Table 1). Peripheral nerve blocks were performed with 0.2% ropivacaine. 68.8% of patients received perineural or intravenous corticosteroids, and all patients received intravenous paracetamol and dexketoprofen before surgical incision. There was no difference between ACB and FNB when pain was measured in the immediate postoperative (NPRS 0.95 vs 1.17; p=0.79) or at 24 hours (NPRS 2.80 vs 3.00; p=0.88) (Figure 1). The mean hospital discharge time was 292 minutes (SD=71), with no differences between spinal and general anaesthesia (p=0.31) or between regional techniques (p=0.47).

ACB and FNB are equally efficacious and the mainstay treatment of postoperative pain after ACLR, as a part of multimodal approach. ACB decreases risk of quadriceps weakness although with low concentration of long-acting local anaesthetic (0.2% ropivacaine) we did not observe prolonged residual motor blockade with FNB. No complications related to regional anaesthesia were reported.

The potential block of the phrenic nerve whilst performing an interscalene plexus block can be devastating in certain patient groups. We present a report where close communication with surgeons and the patient as well as an unconventional approach can help in such cases.

Consent from the (deceased) patients next of kin was obtained. A 72 - year old woman presented with a pathologic midhumeral fracture due to a metastasized lung cancer. The patients history included oxygen - dependent COPD with a 58 - PY - smoking habit. CT showed a large mass in the right lung, saturation was 85% with 2 l/min oxygen, Hb 86. Proximal intramedullary nailing was indicated due to fracture displacement. Given the risks of controlled ventilation on the one hand and diaphragm paralysis on the other hand we opted for a rather unconventional approach.

In order to provide good pain relieve for operation without compromising phrenic nerve function we identified the phrenic nerve, followed its couse along the anterior scalene muscle and opted for a low - volume - supraclavicular nerve block in combination with a suprascapular nerve block and local anesthesia. The patient received additional intravenous Midazolam. The operation was uneventful and the patient recovered well from the fracture.

Our case report shows that it is possible to provide sufficient surgical analgesia without compromising respiratory function for humeral surgery by thoroughly considering anatomical aspects and by having an open dialogue with our orthopedic colleagues.

There are well established procedures for obtaining and documenting informed consent for surgical procedures. Anaesthetic procedures, lack the same standardized approach. This has safety implications for patients and clinicians. We sought to evaluate the patient experience of those who underwent regional anaesthesia (RA) within our department.

Following approval from our audit committee, we conducted a twelve-part telephone survey with thirty patients regarding their experience of RA.The survey explored the circumstances under which patients were consented, and their recall of the information provided.

Of the total number of patients interviewed (n=30), seventy percent (21) believed the NB was compulsory. Sixty percent (18) could not recall any of the possible advantages of receiving a NB and eighty percent (24) could not recall any risks. Sixty-six percent (20) of patients were consented for a NB in the holding bay. Sixteen percent (5) were consented in the induction room. Sixty percent (20) of patients said they would have valued written information regarding the NB. A majority (17) felt they did not have adequate time to consider the NB.Currently there is no formalized process that exists within our department for documentation of the risks and benefits discussed with patients. The practise of which can therefore vary greatly amongst practitioners.

Our results demonstrate a paucity of information that is either delivered to, or retained by, our patients with regards to receiving RA. We aim to distribute a Patient information leaflet to better achieve informed consent from our patients.

The aim is to evaluate the antinociceptive efficacy of pericapsular blocks (PENG-Pericapsular Nerve Group or iliopsoas), residual motor block and functional recovery time after performing these blocks.

Prospective study, comparing 30 patients scheduled for lower extremity surgery between May and June 2021: femoral osteosynthesis, total hip and knee arthroplasty. . Data on the intensity of pain after performing three types of blocks were collected: PENG (pericapsular nerve block), iliofascial and femoral (active control) and comparison was made with cases where no block was performed (passive control). The variables analyzed were: intensity of pain prior to the intervention, type of block performed, degree of motor and sensory block at 24 hours, intensity of pain in the 24 hours postoperatively, duration of the analgesic effect, and need for rescue analgesia. In all cases the same anesthetic technique and perioperative multimodal analgesia were applied.

The PENG block was associated with less motor block at 24 hours. All of them presented a decrease in pain intensity 24 hours after performing the block compared to the previous one. There were no complications attributable to the technique. No significant differences were found between PENG and iliopsoas blocks. Compared with the femoral block, 50% of patients who underwent this block presented motor block 24 hours after the intervention. All of them also experienced a decrease in pain intensity at 24 hours.

The use of pericapsular blocks in hip surgery allow an adequate analgesia that reduces the use of anti-inflammatories and opioids without affecting functional recovery.

Mechanisms of nerve injury related to a peripheral nerve block (PNB) include mechanical trauma, ischaemia and local anaesthetic toxicity. The SAFIRA device aims to reduce risk of mechanical nerve injury. It comprises a motor unit allowing user to aspirate and inject local anaesthetic (LA) on demand preventing LA infiltration pressure over 20 PSI. This study is an international, multicentre, observational, prospective, non- controlled post-market clinical follow up investigation.

Peripheral nerve blocks by anaesthetists trained on SAFIRA were recruited across two sites. Inclusion criteria included patients 18 plus years undergoing elective orthopaedic surgery suitable for PNB. Data yielded included demographic data, PNB type and time to perform & assessment of safety and usefulness of the device and 30 day post PNB follow up. Ethics approval was granted from HRA & HCRW.

128 PNB were conducted with the SAFIRA device (64 from each site). All blocks were successful with no permanent complications reported. 9 patients experienced transient symptoms on initial injection. 3 device malfunctions were reported and due to user error. 82% of the anaesthetists expressed preference for using SAFIRA device.

This study indicates SAFIRA device is safe & effective. We recommend local standard operating procedures are developed to minimise human error. Anecdotally some of the anaesthetists in the study reported using less volume of local anaesthetic compared to their usual practice. This could represent an unintended, but very useful, benefit of the device and warrants further study.

The Peripheral Nerve Blocks (PNB) are becoming a major analgesic technique for the children’s inferior/superior limbs surgery. The objective of this research is to design a formula which will help predict with accuracy the depth of the nerves according to the weight of patients benefitting from PNB.

This prospective and analytical study includes children that will undergo limbs surgery. The PNB were realized with a guided ultra-sound or a neurostimulation. Additionally, the Distance between the Nerve and the Skin (DNS) was measured in all children under study. The data were analyzed by SPSS “20” as well as Stata software for a linear regression.

355 patients were included in this study. The average age was 9,29 ± 4,13 years old and the average weight was 34,7 ± 17 kg. The average DNS was 21,97 ± 10,02 mm. The findings also showed an average correlation R2= 0,48 between the DNS and the children’s weight (P < 0,001). This enabled us to elaborate a formula to predict the length of the needle according to: the weight of the child, the detecting technique and the PNB type realized [DNS (DNP) = 4,33 + 5,48 (technique) + 0,23 (weight) + β (Corresponding to the type of block)

DNS measurement can be a good guide for needle placement in order to reduce the risk of nerves complications.

Theoretically a peripheral nerve block can worsen or delay recovery of a pre-existing nerve injury. We report a patient with pre-existing nerve injury who received continuous peripheral nerve block for uncontrolled pain.

A 22 year-old female, in a motor vehicular accident, sustained near complete degloving wrist to elbow and open fractures of her left forearm. Forearm was pulseless with paresthesia and loss of motor function. Patient underwent emergent revascularization, debridement, and subsequently multiple surgeries. Pain was initially managed with multimodal analgesia. Due to inadequate pain control and increasing opioid requirements, she opted for continuous nerve block after discussion of the risks. A supraclavicular block catheter was placed and attached to an ON-Q system delivering 0.125% bupivacaine at 10 ml/hr. Pain score decreased to 5/10 from 9/10. Catheter was replaced after 4 days after accidentally being pulled then removed after 7 days. Patient reported burning pain of 8/10 after catheter removal. She had undergone a wound flap and had to receive a single shot block. After a trial of multimodals and increasing opioids, patient underwent another supraclavicular nerve block catheter placement which she kept for 5 additional days. A bolus of 15 mL 0.5% was given via supraclavicular catheter prior to removal.

Pain was eventually controlled with multimodal analgesia. Patient regained ability to flex her fingers 3 days after catheter removal.

Although pre-existing nerve injury is not an absolute contraindication to peripheral nerve block, there should be a comprehensive discussion of potential risks and documentation of extent of pre-existing injury.

Introduction: Circumcision is a minor and common pediatric urologic procedure, and standard anesthesia is yet to be defined. The potential benefits of pudendal nerve block (PNB) over dorsal penile nerve block (DPNB) are still controversial. We performed a systematic review and meta-analysis of randomized and observational studies that compared the effectiveness and safety of the PNB versus the DPNB for pediatric circumcision.

PubMed, Cochrane, Embase, and Web of Science databases were searched for this purpose. Statistical analysis was performed with Review Manager 5.4, and the risk of bias was appraised with the Rob-2 and Robins-I tools. PROSPERO CRD42023430520

Five studies were included, comprising 3 randomized and 2 observational studies with 517 patients, of whom 48.7% underwent PNB. Postoperative pain scores were significantly lower in the PNB group at 1, 6 and 24 hours (Figure 1). Rescue analgesia was significantly lower in the PNB group at 0 and 6 hours (Figure 2). There were no significant differences between groups in postoperative pain scores at 0 hours (p=0.18) and at 30 minutes (p=0.22). No significant differences were found in rescue analgesia at 12 hours (p=0.05), and 24 hours (p=0.97), in surgery duration (p=0.25), and in time to perform the block (p=0.31). There were 0/252 (0%) postoperative complications in the PNB group and 2/265 (0.7%) in the DPNB group.

Our findings suggest that PNB may provide better analgesia when compared to DPNB. In addition, both techniques seem to be equally safe and they do not interfere with surgery duration.

The interscalene block in upper limb surgery is a standard technique in managing pain after shoulder surgery, but it has been associated with hemi-diaphragmatic paresis. In contrast to ISB, supraclavicular block was suggested to provide effective anesthesia for shoulder surgery with a low rate of side-effects. This meta-analysis was conducted to analyze the effects of both of these techniques on pulmonary function.

PubMed, Scopus and Cochrane databases were searched for randomized controlled trials that compared Interscalene Block to Supraclavicular Block in patients undergoing upper limb surgery. Heterogeneity was examined with I2 statistics. A random-effects model was used for all outcomes reported with high heterogeneity

We included 14 RCTs with 2449 patients. The meta-analysis revealed that phrenic palsy (RR1.62; 95% CI 1.21-2.16; p=0.001; figure1A) was significantly less common in patients undergoing supraclavicular block compared with interscalene block. Similarly FEV1 (StandartMD -0.36; 95% CI -0.57,-0.17; p=0.001; figure1B) and FVC (Standart MD -0.65; 95% CI -1.07,-0.22; p=0.003; figure1C) were significantly higher in patients undergoing SCB after upper limb surgery. Diaphragm mobility after surgery was not significantly different between groups (MD -0.19; 95% CI -1.87,1.49; p=0.82; figure1D). Regarding the adverse effects Horner's Syndrome (RR 2.36; 95% CI 1.03-5.41; p= 0.04; figure2A) is significantly less common in patients undergoing SCB compared to ISB, while dyspnea (RR 1.57; 95% CI 0.63-3.96; p=0.33; figure2B) and hoarseness (RR 1.27; 95% CI 0.68-2.38; p=0.46; figure2C) were not significantly different between groups.

These findings suggest that patients undergoing supraclavicular block have superior pulmonary function after surgery compared to interscalene block.

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that has been proposed as an effective motor-sparing block for total hip arthroplasty. Recent randomised studies show conflicting results regarding the analgesic efficacy of the PENG block for total hip arthroplasty

Randomised controlled observer-blinded single-centre superiority trial comparing the efficacy of the PENG block with no block for patients undergoing primary total hip arthroplasty under spinal anaesthesia. All subjects received multimodal analgesia consisting of paracetamol and celecoxib. The primary outcome was quality of recovery (QoR) at 24 h as measured by the QoR-15 questionnaire

A total of 112 participants (56 in each group) were included in the analysis. The median (inter-quartile range [IQR]) 24-h QoR-15 scores were higher in subjects who received a PENG block (132 [116e138]) compared with subjects who did not (103 [97e112]) with a median difference of 26 (95% confidence interval, 18e31; P<0.001). Similarly, QoR-15 at 48 h was higher in the PENG group, and opioid use at 24 and 48 h postoperatively was significantly lower in the PENG group. However, we did not find significant differences in pain score, distance to ambulation, or anti-emetic use at any time point. We did not observe any PENG block-related complications.

Adding a PENG block to a multimodal analgesia regimen that includes paracetamol and celecoxib improves the quality of recovery and reduces opioid requirements for patients undergoing primary total hip arthroplasty under spinal anaesthesia

Rebound pain describes an increase in pain sensation after a peripheral nerve block has receded. Theories suggests rebound pain may be due to inadequate pre-emptive systemic analgesia whilst the block is receding, or hyperalgesia after local anaesthetic. Our centre introduced standardised discharge analgesia regimes for upper limb surgery under regional anaesthesia. We sought to identify whether adequate long-acting analgesia and patient education affected our patients experience with day case trapeziectomy under regional anaesthesia.

Following local department audit/QI committee approval patients undergoing elective trapeziectomy, over a year long period and meeting inclusion criteria were discharged with standardised TTOs including 3 doses of a prolonged release opioid and a patient information leaflet. They were followed up by a qualitative telephone questionnaire at 4-6 weeks. These results were compared with a retrospective interview with patients having been identified as having had a trapeziectomy in the 12 months preceding the introduction of standardised TTOs. Results were compared using the Chi squared significance test.

A total of 44 patients met inclusion criteria, 24 pre and 20 post standardisation. Pain scores (p=0.21), and satisfaction (p=0.42) showed no significant difference. Sleep quality trended towards significance (p= 0.067, but significantly fewer patients required to seek further medical help for pain management post discharge (25% vs 0%, p<0.05).

The introduction of long-acting analgesia and patient information leaflets did not significantly alter the post operative pain scores, patient sleep quality or patient satisfaction. However, significantly fewer patients required to see their healthcare provider for further post discharge analgesia.

A 59-year-old ASA IV patient with stage IV lung adenocarcinoma who suffered a pathological fracture of the distal right humerus. It was decided to do a closed reduction and internal fictation by traumatology with a T2 nail of the humerus. This patient was at a high anesthetic risk due to a history of bilateral PTE and pulmonary neoplasia that caused chronic respiratory failure with the need for oxygen therapy at home.

In this case, regional anesthesia was performed under ultrasound control and neurostimulation: Interscalene block with 25ml of 0.375% levobupivacaine. Superficial cervical block with 10ml of 0.375% levobupivacaine. Suprascapular block with 10ml of 0.25% levobupivacaine. Intravenous sedation was performed in spontaneous breathing with nasal cannulas with capnography with: Remifentanil 0.05mcg/kg/min Propofol 3mg/kg/h

Throughout the intervention the patient remained hemodynamically stable and with oxygen saturations of 97-98%. Postoperative pain was well controled without the need of opioids.

This case wants to demonstrate the importance of having regional anesthesia in fragile patients with high anesthetic risk. We see how even in surgeries where general anesthesia is usually required, with a good anesthetic plan we can avoid it and perform the surgery safely and with excellent postoperative pain control, also avoiding the abuse of opioids in these patients.

Peripheral vascular disease (PVD) is a major cause of morbidity and mortality globally, with significant financial burdens on critical healthcare resources. Regional blocks is a widely used anesthesia techniques for high-risk patients with severe coexisting diseases and use of anticoagulants in which general anesthesia and neuraxial blocks is harmful and should be avoided.The aim of this study is to serve as a reminder of its significant value of regional anesthesia blocks in patients who are not appropriate for other type of anesthesia

120 patients underwent a peripheral vascular reconstruction of lower limbs which were performed under either spinal anesthesia I group (30 patients) or regional block II group (n.femoralis, n.ischiadicus, n,obturatorius)with local infiltration at the site of dissection as needed(30 patients)or combined spinal-epidural anesthesia III group (30 patients).Outcomes will include longer-term mortality;major adverse cardiovascular,pulmonary,renal and limb events;delirium;neuraxial or regional anesthesia–related complications;graft-related outcomes;length of operation and hospital stay;costs;and patient-reported or functional outcomes.

Operations included femoral-femoral,femoral-popliteal bypass grafting.Average age of patients 72.7 years.ASA score III-IV.The intra-operative events showed that the mean time needed to perform the block and dose of analgesics and sedatives needed during surgery was greater in group II and III,compared to group I.Local infiltration in the area on the dissection with 5 ml 1%lidocaine was required in patients in group II vs none in the spinal group and combined spinal-epidural technique.

Lower limb vascular reconstruction can be done under regional anesthesia(n.femoralis,n.ischiadicus,n.obturatorius blocks)what can allow to avoid hard complications at patients with high-risk diseases and optimize pain relief for them.

We look at the trends of regiocal anesthesia practice. We also looked at the nicdence of LAST

Serratus anterior plane block (SAPB) is widely performed to relieve pain from rib fractures. In severe chest trauma pain can worsen the patient outcome, pain control can reduce respiratory complications, improves ventilatory mechanics, increasing functional residual and vital capacity, preventing atelectasis and allowing the patients to cough and remove secretions.In ICU SABP is a tool to manage pain in different critical scenarios. We hypothesized to routinely apply SAPB in severe chest trauma, requiring ICU admission and mechanical ventilation (MV), to achieve different goals.

Three example cases. SABP was performed as a single shot, every 24 h, using ropivacaine 0.375% plus dexamethasone 4 mg, using a medium volume of 35 ml.

Opioid sparing: SAPB allowed remifentanil withdrawal in an hemodynamic instability setting, when opioid had a strong impact. Difficult weaning: 1.An obese patient with a massive haemothorax and altered respiratory mechanics.SAPB allowed the pain control due to the chest tube and the patient was free from MV after 5 days. 2.A patient involved in a heavy flood. He suffered multiple bone trauma, including severe chest trauma with rib fractures and lung contusions, he also developed severe pneumonia due to mud inhalation which required intubation after 5 days of hospital stay. The patient was able to be collaborative, we tested Nif before and after 1 h from the block, we were able to wean the patient from MV, tracheotomy was not required

SAPB could be useful in reducing respiratory complications and improve patients outcome in ICU, but further studies are needed

Scapula fractures are uncommon and are usually caused by high energy trauma which are often associated with intrathoracic injury. Treatment is usually nonoperative with imoblization or a sling and rarely requires surgery. This case study aims to discuss a potential regional approach for patients with scapular fractures needing operative repair. Our patient is an 81 year old female with past medical history of obesity (BMI 36), hypertension, coronary artery disease, chronic kidney disease, gastroesophageal reflux, depression, and osteoporosis who presented with a stress fracture at the base of the acromion process of her right scapular from a fall that failed conservative, nonoperative management. She was scheduled for an elective open reduction and internal fixation via posterior approach.

The case began with regional anesthesia. She received a total of 25mL of 0.5% ropivacaine with 60mcg dexmedetomidine for three blocks: interscalene brachial plexus, superficial cervical plexus, and suprascapular nerve blocks. The case proceeded with general endotracheal anesthesia without event.

In PACU, she reported 0/10 pain, without needing any postoperative narcotics prior to her discharge home.

For a posterior approach scapula surgery involving the acromion, a combination of interscalene brachial plexus, superficial cervical plexus, and suprascapular nerve blocks are appropriate for acute pain management of these patients.

Surgical treatment of ankle fracture (AF) is associated with significate postoperative pain. The two peripheral nerve blocks (PNB) used more frequently to provide complete anesthesia/analgesia to the ankle are the sciatic popliteal nerve block (SPNB) and saphenous nerve block (SNB). These PNB may be used as de only anesthesia technique or may be combined with spinal or general anesthesia. The main objective of this study was to compare the postoperative pain scores of patients treated with SPNB and SPNB combined with SNB.

We reviewed retrospectively 51 patients surgically treated to ankle fractures with PNB through the first 5 months of the year of 2023. Thirty-two had SPNB and 19 SPNB plus SNB. The primary outcomes were pain scores at day 1 (D1) and day 2 (D2) postoperatively using the visual analog scale (VAS) score.

Pain scores did not vary significantly when comparing the use of SPNB and SPNB plus SNB. The mean VAS score of SPNB group at D1 was 0.59 +/- 1.16 and of SPNB plus SNB group 0.42 +/- 1.02 (p=0.29). At D2 the mean VAS score of SPNB group was 0.81 +/- 1.44 and the SPNB plus SNB group 0,95+/- 1.43 (p=0.62).

When combined with spinal anesthesia or general anesthesia SPNB may be sufficient to provide postoperative analgesia after AF surgery. The SNB may not add any postoperative analgesic benefit into this group of patients. The combination of SPNB plus SNB may be advantageous when surgery is performed only under regional anesthesia with PNB.

Multiple Intercostal nerve blocks had their role in the clinical scenario for small breast procedures. Agreeing with all new evidence of intercostal space spread of local anesthetic, we present a safe technique to block intercostal nerves by a single injection in the posterior intercostal space.

We aimed to describe two case reports from two Middle-aged Women, one with a diagnosis of breast abscess and the other with a breast expander rejection. After signing the informed consent, both patients underwent the anesthetic procedure with standard monitoring, received light IV sedation, positioned in lateral decubitus with the up arm lying in front of them. A perpendicular line between the scapulae’s spine and the vertebral column was marked and the point of injection was placed 7 cm from the vertebral column. After local anesthesia, a Tuohy needle was inserted into this point at the superior angle of the rib, and a syringe with 4ml of saline was placed to test the loss of resistence (LOR) technique.

As the LOS was positive, lidocaine 2% 20ml with sufentanyl 5mcg was injected in fractionated doses associated with aspiration to avoid intravascular injection. The technique was tracked by an ultrasound image. The onset time was short and the efficacy was high.

These two case reports come from the anatomical studies of the intercostal space, where some authors discussed the possibility of blocking many nerves with a single injection. A little change in the published technique and the addition of the ultrasound could make it safer.

Liposomal bupivacaine (LB) may provide analgesia up to 96 hours following single shot injection. Its role in perioperative pain management regimen is still emerging(1). As a part of on-going quality improvement (QI) project, we introduced LB in peripheral nerve blocks (PNBs) for patients who admitted with fracture neck of femur (NOF) requiring extended optimisation prior to surgery. We aimed to audit the place of LB as an alternative to the continuous catheter technique.

Info poster was introduced. Ultrasound-guided PNBs were performed by the regional anaesthetists at ward setting on the request of trauma or acute pain team. We examined the pain scores at rest and on movement, opioid and anti-emetic use, and time until first mobilisation post-operatively over 96h duration.

20 patients received PNB with LB. FICB was performed in 100% along with PENG block in 40%. Pain scores across the first 96 hours post-PNB are displayed in figure 1. During the hospital course, 40% of patients required opioid prior to PNB, and thereafter it had been reduced to 5%, 15%, 0% 15% and 15% in consecutive day 0 to 5. Neither of them were required antiemetics nor limited mobility due to pain on within first 24 hours.

PNB with LB may beneficial in vulnerable patients with fracture NOF who may wait beyond the window period for surgery as a part of multimodal analgesia. However, a case series may not enough to demonstrate a reliable outcome and formal clinical trials are needed to establish the true contribution of LB.

The Erector Spinae Plane (ESP) block is a good perioperative analgesia for thoracic, chest wall, abdominal, spinal and hip surgeries. A recent case report had demonstrated its efficacy in post-operative analgesia for an above-knee amputation, but no reports have been published on ESP for surgeries below the level of the knee. The authors would like to publish the first case report of effective use of lumbar ESP block with catheter for intra and post-operative analgesia for an extensive tibia endoprosthesis surgery.

We report a 12-year-old male with non-metastatic osteosarcoma of the right proximal tibia undergoing tibia endoprosthetic surgery. ESV and his mother were keen for a block for supplemental analgesia but not involving the central neuraxial axis, so a lumbar ESP at L3 level was proposed. ESV was given a general anaesthetic and an ESP with catheter was sited at the level of the right L3 transverse process.

The patient underwent a 7-hour long resection of tumour and insertion of tibia endoprosthesis for which the ESP initial bolus was effective in achieving good intraoperative analgesia. Post-operatively, the ESP catheter was used to deliver programmed intermittent boluses (PIB) of local anaesthetic for analgesia in the first 3 post-operative days, while facilitating ambulatory physiotherapy.

Our patient had demonstrated the efficacy of a lumbar ESP block in delivering good intraoperative analgesia for lower limb surgery. It also demonstrates that the continued use of a lumbar ESP catheter for PIB local anaesthetic boluses affords adequate analgesia without significant motor block and impediment to physiotherapy.

Axillary base arteriovenous bypass graft (AVBG) is one technique for hemodialysis access modality for patients with end-stage renal disease. Brachial plexus block is an anesthetic technique of choice that could have a direct effect on venous diameter as well as intra- and post-operative blood flow. However, it could not provide anesthesia for T2-T3 dermatomes. Additional intercostobrachial nerve block should have complete anesthesia for this surgery.

We conducted a prospective randomized control trial. A total of sixty-two patients with chronic renal failure scheduled for axillary base AVBG were randomly divided into two groups: group P (PECS II block group; n=31) and group S (Serratus anterior plane block group; n=31). Ultrasound-guided costoclavicular brachial plexus block was given to both groups with 0.33% bupivacaine 15 ml. The primary outcome was a complete sensory and motor block of the C5-T3 dermatome. The secondary outcome included time spent blocking, the onset of analgesia, adverse events arising from anesthesia, and surgeon and patient satisfaction.

There were no statistically significant differences between both groups regarding block performance time and the onset of sensory and motor block in the areas supplied by C5-T3 (p = 0.74) mean block time 10.84min (P 10.18 min, S 11.49 min) mean onset 15.95 min (P 15.74min, S 16.16min). No significant difference regarding anesthetic adjuncts during surgery, adverse effect, complications, and surgeon and patient satisfaction.

Both approaches can provide satisfactory sensory and motor blocks for chronic renal failure patients undergoing an axillary base AVBG.

Short-term hypertension (HT) after Interscalene block (ISB) has been reported in quite few studies (1). In addition to the known side effects of HT, increased surgical hemorrhage may disrupt visual clarity. Therefore, the present study aimed to review the incidence and associated risk factors of hemodynamic changes after ISB using 15 mL of 0.375 % bupivacaine for arthroscopic shoulder surgery in the lateral decubitus position.

The follow-up forms of anesthesia, medical records of adult patients without HT were evaluated retrospectively. Systolic and diastolic pressure, heart rate, and peripheral oxygen saturation (SpO2) were recorded before and at five-minute intervals after block performance and during surgery.

A total of 99 patients were recruited, and all of them were sedated with midazolam and fentanyl prior to needle insertion. At the 30th minute after ISB before surgery, a 20% increase was observed in 12.1 % of patients, compared to the baseline blood pressure (BP). Systolic arterial pressure was found to be >140 mmHg in 7.07% and >180 mmHg in 2.02% of the patients. No differences in heart rate and SpO2 were noted. Antihypertensive medication was administered to 2.02% of patients despite sedation with dexmedetomidine/remifentanil infusion. Such features as age, comorbidities, duration of surgery, and gender had no statistically significant effect on HT (p>0.05).

Some spread of local anesthetic after ISB would cause a blockade of carotid sinus baroreceptors leading to an increase in BP. This should be considered in patients with cardiovascular diseases or poorly controlled HT, especially in awake patients under regional anesthesia.

Rib fractures are common in polytrauma patients and require effective analgesia to prevent respiratory complications. Optimal pain management requires multimodal approach including regional anesthesia. Ultrasound-guided erector spinae plane block (ESPB) with catheter placement allows good pain control, improves respiratory outcomes and has negligible risk. Our aim was to present a case series of 11 patients with multiple rib fractures whom thoracic ESPB with catheter placement was performed for analgesia.

We present a case series of 11 patients, between 41-80 y-old and mostly ASA II whom thoracic ESPB was performed for pain management. All patients were referred to the acute pain unit due to uncontrolled pain and/or worsening respiratory function. Thoracic ESPB with catheter placement was performed and an analgesic regimen such as PCA (infusion and/or bolus) or PIEB was applied.

The number of broken ribs varied from 5-10, and in one of the cases the patient had bilateral rib fractures. Four received non-invasive ventilation and 2 mechanical invasive ventilation. Six of them had pulmonary contusion, 3 evolved to pulmonary infection. Nine patients were under PCA (infusion and/or bolus) and 2 patients under PIEB regimen. In all patients ropivacaine 0,2% was the chosen local anesthetic. In all cases there was an improvement in pain scores 24h after ESPB. The mean PaO2/FiO2 ratio was higher in all patients 24h after catheter placement.

Further investigation on ESPB with catheter placement should be made as it may be an alternative to epidural or thoracic paravertebral block in patients with multiple rib fractures.

A 50 years old, male patient, was scheduled for surgical repair of rotator cuff injury. An interscalene approach to the brachial plexus was selected to provide analgesia and was combined with general anesthesia (TIVA). During the immediate post-operative period, the patient developed shortness of breath and complained for easy fatigue, which, after a detailed examination, were attributed to a paralysis of the right phrenic nerve, resulting in the elevation of the right hemidiaphragm and causing the symptoms. This was considered a complication of the interscalene block.

After six months with no improvement, a restoration of the diaphragm with thoracoscopic technique was decided. The patient was scheduled for diaphragm plication. The anesthesia was performed with paravertebral block and general anesthesia (TIVA). Throughout the 6 hours long surgery, the patient remained hemodynamically stable, while he didn’t present any other analgesic demands. After the operation, the patient was extubated and his level of analgesia was assessed, based on NOL (15) and VAS (2) scales.

Throughout the 6 hours long surgery, the patient remained hemodynamically stable, while he didn’t present any other analgesic demands. After the operation, the patient was extubated and his level of analgesia was assessed, based on NOL (15) and VAS (2) scales.

Paravertebral block is an attractive regional anesthetic technique, as it can provide excellent unilateral analgesia, with a low rate of hypotension compared to epidural anesthesia for thoracic and abdominal procedures. In our case, paravertebral block was proved an efficient analgesic technique for a long and laborious time operation.

A 72 years old, male patient with fractures in 6 consecutive ribs, three of which in multiple places, arrived at the ER ward, after a fall from a ladder. The CT scanning revealed no pneumothorax or hemothorax. The patient complained about severe chest pain, shortness of breath, progressively getting worse. At the same time, tachypnea, intense sweating, hypertension and tachycardia were clinically observed.

To relieve the patient, it was decided to perform a thoracic paravertebral block at two levels, in one of which a continuous drug infusion catheter was placed. A PCRA pump was used and the patient was immediately relieved. He was transferred to the PACU due to the severity of his injury and remained there for two days.

Being respiratory stable and in good clinical condition, he was transferred to a simple ward and after 4 more days, without presenting any complications, it was decided to remove the catheter. The patient was then treated with mild analgesics such as paracetamol and tramadol and a week later he left the hospital, presenting a satisfactory and stable clinical condition and instructions for p.o analgesia.

To our knowledge this was the first time that a paravertebral block was used as an analgesic method for multiple rib injuries. In our patient the thoracic paravertebral block was probably the cause of the non-appearance of the expected respiratory complications (hypoxemia, atelectasis, respiratory failure, pneumonia, intubation, hospitalization in the ICU) and contributed to the rapid recovery of his severe injuries.

systemic toxicity of local anaesthetics (LA) is a rare but often dreadful event. Its prevention relies essentially on good knowledge of the products used, as well as consideration of the various safety measures. The aim of our study is to evaluate the knowledge of anesthesia technicians (AT) concerning the use and management of local anesthetic poisoning

Descriptive and analytical cross-sectional study carried out among AT in university hospitals . To achieve our research objective, the study was carried out using an anonymous, self-administered declarative anonymous questionnaire.

Although the results of this study showed that only 20% of the participants had witnessed LA intoxication, we found that the majority of those questioned know the principles of care, except for a few particularities, such as the dose of intralipid recommended by the SFAR (known by only 31% of respondents). From similarly, our study showed that 63% of the AT had received ALR training. The formation was based on courses received during the anesthesia resuscitation curriculum according to 61.9%, hence the need to develop ALR simulation centers and more clinical practice.

this work has highlighted the fact that knowledge of the specific characteristics of LA, how to do in the event of toxicity, is essential to ensure the proper in the event of an accident. .

Aortic-bifemoral bypass is a surgery chosen for patients with Leriche syndrome or severe peripheral arteriopathy. This procedure implies a laparotomy supra and infraumbilical. That translates into a severe pain during postoperative period. Therefore, pain management becomes a key pilar for early recovery. Cardiovascular anesthesiologists usually choose low thoracic epidural to control pain. However, the circumstances of some patients make it a non-feasible technique. In those cases, abdominal wall blocks are a valid alternative reducing pain, morbidity and the length of stay in hospital.

We expose a case in which a bilateral transverse abdominis block with a single shot technique was performed on a patient who was elected for aortic-bifemoral bypass.

A woman 61 years old is elected for aortic-bifemoral bypass due to Leriche syndrome. In our hospital our gold-standard technique is thoracic epidural at a t10-t11 level. However, in this case she had systemic sclerosis, so we decided to perform a bilateral transverse abdominis block with a posterior approach at the level of Petit´s triangle. We administered levobupivacaine 0,25% with a volume of 40 ml in total. During the first 48 hours in the ICU, she received an elastomeric pump consisting of dexketoprofen, metamizole and ondansetron. She didn’t have irruptive pain either she got any opioid rescue analgesia.

Bilateral transverse abdominis plane block is a valid alternative to thoracic epidural in aortic-bifemoral bypass. Transverse abdominis plane block with a posterior approach can give a sensory block from T7 until L1.

Endophthalmitis is a severe intraocular inflammation that can occur following surgery or eye trauma. Wound infection has been described as a primary foci of infection in endogenous endophthalmitis. We present a case of purulent endophthalmitis treated with immediate pars plana vitrectomy (PPV) under peribulbar block and conscious sedation.

A 75-year-old male patient, with multiple cardiovascular risk factors, underwent open aortic valve replacement, and was readmitted one month later with sternal wound infection. He received antimicrobial treatment. Four months later, the patient presented with purulent endophthalmitis. PPV ensued under peribulbar block and conscious sedation with a propofol perfusion. Peribulbar block was performed with two injections of Ropivacaine 1%: inferior-temporal (5mL) and superior-nasal (3mL), to ensure adequate spread within the intraconal and extraconal spaces.

Peribulbar anaesthesia allowed akinesia and good surgical conditions with respiratory and hemodynamic stability. The surgical procedure was performed successfully without perioperative complications.

Peribulbar anaesthesia is a feasible anaesthetic technique for PPV, as it allows akinesia during surgery, better hemodynamic stability, and fewer postoperative complications, especially in older fragile patients with comorbidities. PPV performed under peribulbar block can be considered a reliable approach in managing purulent endophthalmitis, offering a safe alternative to general anaesthesia.

FESS (functional endoscopic sinus surgery) is a minimally invasive approach for paranasal sinuses surgery that treats numerous symptoms avoiding more complex surgical procedures. It is usually performed under general anesthesia, our aim was to find a suitable locoregional technique that could match the minimally invasive approach of the surgery.

Written informed consent was obtained from a 32 y/o male patient, ASA I. We performed bilateral infratrochlear nerve block with 1,5ml ropivacaine 7,5mg/ml for each side, bilateral infraorbital nerve block with 4ml ropivacaine 7,5mg/ml for each side, bilateral anterior ethmoidal nerve block with 3ml ropivacaine 7,5mg/ml for each side. All blocks were perfomed with standard 26G needle without ultrasound, using anatomical landmarks. Efficacy was tested via pin-prick test and endoscopic puncture of mid-turbinate by ENT specialist. Standard multiparametric monitoring and NOL PMD200™ monitor (Medasense Biometrics Ltd., Ramat Gan, Israel) were used to assess nociception levels during surgery.

The surgery was performed without complications with continuous infusion remifentanil (0,05 mcg/kg/min). No significant hemodynamic shift was registered during surgery and no other opioid was administered. NRS level was 0 at the end of the surgery as well as at patient discharge 3 hours later.

This locoregional technique has shown promise for FESS surgery, and we think it may be suitable for septoplasty and fracture repairs too. We plan to conduct a randomized control trial to further study the matter.

Ultrasonography has recently emerged as one of the most valuable equipment for anesthesiologists during the whole perioperative period. The aim of this report is to describe diagnosis and follow-up of a patient who developed phrenic nerve paralysis during interscalene block performed with nerve stimulator.

A 71-year-old woman with known hypertension was scheduled for surgery for supraspinatus muscle tear. The patient underwent an interscalene block with 25 cc 0.5% bupivacaine using nerve stimulator. The patient was transferred to post anesthesia care unit with a possible diagnosis of phrenic nerve paralysis as the SpO2 value was 88% and needed O2 of 8 L/min. Ultrasonographic examination revealed diaphragmatic paralysis as the excursion was only 1.6 cm (Figure 1). During the follow-up the patient’s diaphragm movements recovered and she was transferred to ward with an excursion measured 4.1 cm and SpO2 of 96% in room air (Figure 2)

Interscalene block is associated with hemidiaphragmatic paralysis as a result of phrenic nerve block[1]. It is usually a benign condition and resolves spontaneously but close monitoring may be needed in some cases. In this case, in addition diagnosing the pathology, ultrasound improved patient safety by enabling real-time diaphragm monitoring.

In addition to improving safety during regional anesthesia practice, ultrasonography may also play an important role during management of the complications. [2].

Chronic cough is cough lasting for more than 8 weeks, with a multifactorial cause including a hypersensitivity of the internal branch of the superior laryngeal nerve. Cough following esophagectomy in patients with esophageal carcinoma has been commonly associated with gastric reflux in 20-80% of patients. However, very few literature has described cough secondary to superior laryngeal nerve irritation as a complication of esophagectomy. Recent literature described the use of superior laryngeal nerve block using lidocaine and steroids for patients presenting with neurogenic cough. This paper presents a case of a 48 year-old male post-esophagectomy with gastric pull-up, complaining of persistent cough unrelieved by medical management.

Trigger points of cough were identified. Superior laryngeal nerve block using lidocaine with dexamethasone was done, which resulted to immediate relief. However, symptom recurred in less than 24 hours. Six days after, the procedure was repeated using lidocaine with epinephrine and triamcinolone acetomide.

Cough severity index score of patient decreased from 40 to 20, with 70% decrease in the frequency of symptom. However, patient also noted a transient difficulty in swallowing.

Superior laryngeal nerve block using lidocaine and steroids is a possible modality in the diagnosis and treatment of neurogenic cough as a complication of esophagectomy. Its effect is, however, temporary and should be done repeatedly to achieve significant results. Further studies should be done to determine the most effective combination of local anesthetic and steroid to achieve a desirable prolonged relief. One of the possible complication of the procedure is dysphagia.

Background: Severe pain from sacral fractures can be difficult to treat especially in the parturient where systemic analgesia options are limited by its maternal and fetal side effects. Regional anaesthesia can be especially useful in providing analgesia due to its minimal side effects. Aims: We postulated that a sacral plexus catheter can help achieve our goals of 1) long-lasting pain control without need for repeated procedures, 2) minimal maternal and fetal side effects, 3) facilitating physiotherapy and rehabilitation, and 4) early home discharge.

We detail the case of a 30-year-old 16-week parturient with traumatic sacral fractures. Despite optimal multimodal analgesia, our patient experienced debilitating pain affecting her breathing, sleep, and rehabilitation. As analgesia options were limited, regional anaesthesia techniques including a sacral plexus catheter, caudal and lumbar epidural block were offered. A right sacral plexus catheter was eventually inserted for pain relief, using the parasacral parallel shift approach under ultrasound guidance. An initial local anaesthetic bolus of 15mL Lignocaine 1.5% with adrenaline 1:200,000 was injected, followed by a continuous infusion of Ropivacaine 0.2% at 5ml/h. She was followed up daily by the Acute Pain Service team.

With the sacral plexus catheter, our patient experienced significant pain relief and rehabilitated well. She reported improvement in pain with from a Numeric Rating Scale of 10 to 2 post-procedure and recovered sufficient function for home within 1 week.

We conclude that a sacral plexus catheter is a good viable option in providing analgesia and facilitating rehabilitation in the parturient with traumatic sacral fractures.

Tenolysis requires complete division of tendons followed by early mobilization. Rapid development of adhesions following surgery necessitate adequate analgesia to facilitate early active exercise programmes. Regional anaesthesia provides superior pain relief and reduces opioid requirements. A continuous ambulatory catheter allows for the patient to recuperate outpatient and shortens hospital stay while maintaining good post operative analgesia. Targeting distal terminal branch nerves also reduces the incidence of motor block thus facilitating physiotherapy and recovery.

A 50-year-old woman presented with post operative stiffness of left ring finger following open reduction and internal fixation of proximal interphalangeal joint fracture. In view of her limited active range of motion, she underwent removal of implants and tenolysis of flexor and extensor tendons under regional anaesthesia with an infraclavicular brachial plexus block. Following surgery, ultrasound guided insertion of median and ulnar nerve catheters at the level of the forearm was performed and continuous infusions of 0.2% Ropivacaine via two balloon infuser pumps was started. The patient was guided on care of outpatient catheters and allowed to self-titrate the infusion rates to maintain analgesia while avoiding excessive motor blockade.

On post operative day six, she was able to move fingers with minimal pain and oral analgesia and catheters were removed by herself the next day.

This case highlights the use of ambulatory catheters for post operative analgesia in the outpatient setting to promote early physiotherapy.

Triple monitoring (TM) involves the use of a nerve stimulator, ultrasound imaging and a pressure limiting device (PLD), particularly when performing plexus blocks and peripheral nerve blocks (PNB). Alongside performing regional anaesthesia (RA) in awake patients, TM is seen as the gold standard in monitoring. The aim of this study was to determine how anaesthetists monitor their administration of RA.

Fifty peripheral nerve blocks were audited for monitoring standards. Documentation for each block was retrospectively analysed. In addition, a survey was sent to all anaesthetists to gather current monitoring standards used in regional anaesthesia, and knowledge regarding how to use pressure limiting devices and nerve stimulators.

One peripheral nerve block (2%) was performed using a PLD. In 22% of cases a nerve stimulator was used in addition to ultrasound imaging. Ultrasound imaging was used in all cases. The survey had 29 respondents. Twelve percent claimed to use TM whenever performing a PNB. One third of respondents admitted to never using a nerve stimulator when performing regional anaesthesia. Only 32% of respondents were aware that a response to stimulation seen at 0.4mA should raise concerns regarding the possibility of intraneural injection.

Routine follow up after RA is not seen in most anaesthetic departments. The presence of nerve injury as a result of RA may also be over-reported, since the incidence may be confounded by a injury caused surgically. In the absence of a formalised follow up pathway, we should be aiming to follow best practice and use TM when performing PNBs.

Regional anesthesia has been used for hand surgeries for many years, but a recent technique has been becoming increasingly popular: the “wide-awake local anesthesia no tourniquet” (WALANT). This allows the combination of sensitive block and a bloodless field, with preservation of motor function.

We selected a 63-year-old male patient with an old traumatic tendon section in the first finger of his hand that resulted in loss of mobility. One year later, he was proposed for tendon transposition from the second to the first finger to reestablish total abduction ability. The patient only had grade 1 obesity. We performed ultrasound guided peripheral nerve blocks of the radial, ulnar and median nerves at the forearm level, which preserved motor function during the surgery and guaranteed loss of pain sensation. To obtain a bloodless field without a tourniquet, we performed ultrasound assisted subcutaneous infiltration of lignocaine and epinephrine on the dorsal surface of the hand.

The surgery lasted two hours, and the size of the transposed tendon was deemed appropriate through intraoperative observation of ideal hand mobility (see QR code). The orthopedics team confirmed optimal surgical field conditions with this technique. The patient was evaluated at 1 month and, with physical therapy, regained almost all mobility of the hand and showed immense satisfaction.

For hand procedures where there’s an advantage in evaluating motor function throughout the surgery, the WALANT technique proved itself to be an excellent anesthetic choice. Therefore, this technique should be considered more frequently when these surgeries take place.

Lower limb amputation is a procedure usually performed under general or neuroaxial anaesthesia. However, in certain cases as patients in multiorgan failure, peripheral nerve blocks are the only viable alternative for anaesthesia.

A 68-year-old male presented with an acute limb ischemia complicated by an infected ulcer leading to sepsis and multiorgan failure. The patient had a history of diabetes, myocardial infarction and triple vessel disease waiting for CABG. Considering the patient's cardiac condition, septic status, acute kidney injury, acute liver failure, general and spinal anaesthesia was deemed high risk. Therefore, a combination of iliac fascia, subgluteal sciatic and obturator blocks was proposed for anaesthesia to a life-saving transfemoral amputation. The procedure was carried out under sedation with dexmedetomidine and ketamine.

The patient had adequate anaesthesia and remained hemodynamically stable throughout the surgery and the postoperative period. Sedation in this procedure was required for the comfort of the patient and analgesia adjuvant.

Sepsis induced multiorgan dysfunction is a challenge for the anaesthesiologist due to general and spinal anaesthesia side effects. Nerve blocks with sedation could be a safe alternative for anaesthesia in septic patients proposed for limb amputation.

Root cause analysis (RCA) was used to analyse an adverse event: a wrong-sided nerve block was performed in our trust. A junior anaesthetist performed the block with direct consultant supervision. Ultrasound was required for intravenous access; with the machine then used to perform a supraclavicular nerve block on the same (nonoperative) arm of the patient. The error was realised, duty of candour extended, and the incident reported. Wrong-site nerve block is classified as a ‘Never Event’ in the UK by the Healthcare Safety Investigation Branch. Our aim was to raise awareness and identify factors contributing to the error to improve patient safety.

Systematic analysis using the 'Swiss Cheese Model' and Patient Safety Incident Response Framework were used to identify limitations at individual and organisational levels. These were shared with the multi-professional team. Feedback was welcomed, with focus on determining system errors, strengthening existing protocols and preventing recurrences.

Human factors alongside non-technical skills such as team-roles, ergonomics and equipment were identified as major contributors to the error. These are recognised as important for safety in high-risk industries. The lack of situational awareness alongside task-focused behaviour contributed to the omission of the usual practice of ‘Stop Before You Block’ bypassing a mechanism designed to identify errors before they occur.

An open culture of incident reporting and performance feedback within a non-judgemental environment is critical for effective RCA and improved patient safety. Whilst the risk of human error cannot be entirely mitigated, steps can be implemented to recognise situations when errors may occur.

Spinal-epidural anesthesia is a well-established technique for performing cesarian-section. Accidental dural puncture during this procedure is a possible complication, especially in obese obstetric patients.

A morbidly obese 30-year-old with a body mass index of 59 was proposed for elective cesarian-section and myomectomy. We performed a spinal-epidural technique, and there was an accidental dural puncture with a Tuohy needle 18G. Given her phenotype, we had previously discussed the possibility of introducing the catheter in the intrathecal space if this complication took place. We followed up with our plan B, which allowed the administration of continuous spinal anesthesia. At the end of surgery, we administered intrathecal morphine, and the catheter was removed.

The surgery lasted one and half hours, and the patient was always hemodynamically stable. The newborn had an Apgar score of 9/10/10. We explained the potential complications to the patient, and she was evaluated daily during her hospital stay, without developing headache or other symptoms. There was no record of her visiting urgent care in the following days.

We need to be alert for the higher possibility of accidental dural puncture in obese pregnant women, the complications that might arise, and, as such, always have a plan B. In this case, we were able to provide optimal surgical conditions and effective post operative analgesia.

Transverse myelitis (TM) is a rare immune-mediated spinal cord disorder. Acute TM during pregnancy is poorly described in the literature and anaesthetic management of these women is still conflicting.

A 28-year-old patient was diagnosed with idiopathic TM at 15-weeks gestation. She had no medical history besides a previous caesarean section (CS) with neuraxial anaesthesia (NA). Symptoms began with paresthesias in the left lower limb and imaging of the spine revealed a medullary lesion at C5.

At 39 weeks, she was proposed for an elective CS. She had no neurological symptoms at the time. An epidural anaesthesia was performed by a senior anaesthesiologist at first attempt. A total of 14mL of 0.75% ropivacaine and 10ug sufentanil were administered. There was no sensory block after 20 minutes. The technique was considered failed and a general anaesthesia (GA) was performed, uneventfully.

TM has occasionally been attributed to the use of NA and GA. It is also controversial whether patients acutely affected by or recovered from TM are at risk for disease recurrence when NA is administered. Nevertheless, GA is the most reported technique for CS and NA has increasingly been regarded as safe. To our knowledge, this is the first report of NA failure in a patient with history of TM and we cannot discard TM as the reason for failure. This report reaffirms the need for further investigations and the careful consideration of the risks and benefits of NA for CS of women affected by TM.

IPAH corresponds to sporadic disease without any family history of PH or known triggering factor with mPAP > 25 mm Hg or more at rest after excluding left sided heart disease and certain other disorders[1].Pregnancy in IPAH patients is associated with very high peri-partum mortality and conception is not advised and if detected early in pregnancy, then termination is advised[2].

Parturient,37years,at 35 weeks gestation,in premature labour was referred to us being diagnosed as IPAH;NYHA Class III,on Tab.Sildenafil 12.5mg BD and Inj.Enoxaparin 40mg s.c. Post high risk consent,LSCS done under lumbar epidural anaesthesia with 0.25% Bupivacaine+Fentanyl,with standard monitoring and intra arterial line,maintaining hemodynamic stability.Intra-op BP decreased twice,treated with Phenylephrine 50mcg iv bolus & rest was uneventful.Patient monitored in CCU for 48hours;on continuous epidural 0.125% Bupivacaine infusion,with uneventful post operative period.

During pregnancy the circulatory and haematological changes which occur can lead to increased peri-op mortality and morbidity in patients of IPAH.The anaesthetic goals are Maintenance of adequate Systemic Vascular Resistance (SVR);Maintenance of intra-vascular volume and venous return;Avoidance of aorto-caval compression;Prevention of pain, hypoxemia,hypercarbia and acidosis which may increase Pulmonary Vascular Resistance(PVR) and avoidance of myocardial depression.The choice of anaesthesia for LSCS in patients with IPAH is controversial as there is no established anaesthetic protocols to manage such patients and varied reports make it difficult to come to a well-established decision.

Epidural anesthesia can be safely administered during LSCS in a selected group of patients with IPAH,using a multi-disciplinary team approach and extreme vigilance leading to a good maternal and fetal outcome.

Adhesive arachnoiditis (AA) is a chronic, rare and debilitating disease. Characterized by persistent arachnoid inflammation leading to intrathecal scars and dural adhesions, resulting in ischemia, encapsulation, and atrophy of nerve roots. Clinical manifestations include chronic back pain and variable neurological deficits. Anaesthetic challenges include chronic pain management, baby withdrawal syndrome and difficult neuraxial approach.

A 39-year old pregnant woman was scheduled for elective cesarean section due to maternal pathology. Presented with adhesive arachnoiditis, severe lumbosciatalgia, and treated pregestationally with hydromorphone, morphine, baclophene, gabapentine and diazepam. Showed neurologic deficits such as gait impairment, urinary incontinence, spasticity and paresthesia of the lower limbs. Other relevant history included: Chron’s disease, asthma, obesity, gestational diabetes and multiple previous vertebral procedures. General anesthesia was induced using propofol and rocuronium, and maintained with sevoflurane. Tracheal intubation accomplished through videolaringoscopy. Intraoperative analgesia included fentanyl, paracetamol and ketorolac. Multimodal postoperative analgesia was ensured, combining a bilateral TAP block using ropivacaine, paracetamol, ketorolac and a fentanyl Patient Controlled Analgesia (PCA).

Successful cesarian section performed under general anesthesia, with no complications for mother or baby. Postoperative daily evaluation revealed mild pain and nausea, treated effectively with ondansetron. Fentanyl PCA was suspended 48 hours postoperatively.

AA patients can be challenging for the anaesthesiologist due to limitations in the neuraxial approach - an especially important anaesthesia technique in labour - and the management of postoperative acute pain in a patient with chronic pain. The described approach may be a safe and effective choice for AA patients undergoing cesarian section.

Single-shot neuraxial techniques are not useful for most labor analgesia. Intravenous patient-controlled analgesia (iv-PCA) is indicated for parturients who cannot receive neuraxial analgesia. We present two cases managed with a combined single-shot technique and iv-PCA.

Case 1: A 37-year-old, G1P0 woman presented at 19 weeks gestation for abortion indicated with fetal abnormalities. She had a medical history of thoracic to lumber spine surgery for scoliosis. We determined continuous epidural analgesia was not possible and choose a combination of single-shot spinal anesthesia combined with iv-PCA. Before cervical dilatation procedures, 200 mcg of morphine with 7.5mg of bupivacaine was administered intrathecally using a 25-gauge needle. Following induction with prostaglandin E2, iv-PCA with fentanyl (10 mcg/h, 25 mcg/bolus, lockout time 10 min) was initiated. Standard monitors were placed, and the respiratory monitored with ETCO2 continuously until 24 hours after administration. The low dose of naloxone was administered to manage opioid side effects such as pruritus or nausea. Pain control during labor was adequate and the parturient was delivered without serious complications. Case 2: A 27-year-old, G5P0 presented at 21 weeks gestation for abortion indicated with a fetal abnormality. She was not eligible for epidural analgesia due to anticoagulant therapy. 200 mcg of morphine with 10mg of bupivacaine was administered and then the same protocols were used in this parturients. Pain control during labor was good and opioid side effects were well controlled with naloxone.

A single-dose technique combined with iv-PCA provided adequate labor analgesia in mid-term delivery without serious complications.

Morbid obesity can increase epidural failure rates in emergency C-sections but can decrease incidence of post-dural puncture headaches (PDPH). This makes continuous spinal anesthesia (CSA) an attractive choice for labor analgesia for the morbidly obese parturient.

A 34-year-old, G8P7, with hypertension, diabetes, asthma, and BMI 58 was admitted for labor augmentation. G1 was a C-section, G2-G7 were VBACs with epidurals. G7 delivery was complicated by shoulder dystocia. For G8 pregnancy, CSA was performed. Loss of resistance to saline was obtained with 17g Tuohy needle and advanced until CSF was seen, 20g catheter was threaded intrathecally. 1 ml 0.125% Bupivacaine with Fentanyl 2mcg/ml was given as bolus, then infused at 2ml/hr. Large visible labels were placed on the intrathecal catheter, medication pump, and patient door. Thorough report was given to the next anesthesia provider at the end of shift.

Adequate labor analgesia was obtained. Patient delivered vaginally 5 hours later. The intrathecal catheter was left in situ for 24 hours from placement. No headaches were reported. The choice of anesthetic technique took several variables into consideration: anesthesia staffing, number of laboring patients, potential emergency cases, obstetric team threshold of converting to a C-section, and patient specific risk factors.

Although not the first line for labor analgesia, CSA is a safe and reliable alternative for certain patient population. It provides visual confirmation with CSF aspiration and can be dosed for quick onset and dense block in an emergency C-section.

Achondroplasia accounts for approximately 70% of all forms of dwarfism. Cesarean delivery is often required in parturients with achondroplasia due to cephalopelvic disproportion. Given the challenges for both regional and general anesthetic techniques, there is no consensus on the optimal anesthetic management for cesarean delivery in these patients. The aim of this study was to explore the literature for prior case reports and series to determine the optimum anesthetic management for cesarean delivery in achondroplastic patients.

We conducted a review of the literature using Embase, Medline, and Scopus database searches for case series and case reports on achondroplasia and pregnancy through May 2023. Extracted data included demographic information, anesthetic management, and reported complications. Institutional IRB exemption was obtained.

Literature review resulted in 49 manuscripts with a total of 62 anesthetics. Anesthetic management consisted of general anesthesia (n=15) (Table 1), single injection spinal (n=23), epidural catheter (n=13), combined spinal-epidural (n=10), and intrathecal catheter (n=1) (Table 2). Reduced dose of bupivacaine was common, and few complications were reported.

Despite the risks attributed to general anesthesia in parturients, it was historically the preferred anesthetic management in achondroplastic patients due to unpredictable spinal anatomy and unreliable local anesthetic spread. We describe a review of the literature in which neuraxial anesthesia is increasingly more common and a viable option in carefully selected parturients with achondroplasia. Reduction of intrathecal local anesthetic that minimizes the risk of high spinal and emergent intubation, as well as a titratable neuraxial technique can be effective in this patient population.

The main goal of an epidural test dose (ETD) is to avoid the inadvertent injection of large doses of opioids and local anaesthetic either intravascularly, subduraly or intrathecally. Although some literature suggests that the ETD is not an effective method for identification of epidural catheter (EC) misplacement in obstetrics, it is still common practice in many maternities.

We review 3 clinical scenarios of complications after the administration of epidural anaesthesia or analgesia, where the ETD failed to reveal the catheter misplacement.

The first case report refers to a pregnant woman who received a sequential block for labour analgesia. An ETD with lidocaine was administered after the technique. One hour later an epidural dose for analgesia was administered, which caused a complete motor block with hypotension and fetal distress. The second case describes an epidural technique for labour analgesia, followed by an uneventful ETD with lidocaine and epinephrine. Shortly after a ropivacaine bolus, the patient developed a patchy block and a Horner syndrome. The third case refers to a caesarean section with an EC already in place, tested with a lidocaine bolus. After the administration of ropivacaine for surgical anaesthesia, the patient developed severe respiratory distress with the need for mechanical ventilation.

There are many cases in literature where the ETD was ineffective and even associated with adverse events. These three case reports show that the ETD does not prevent the occurrence of adverse outcomes. More studies are required to establish which strategy is valid for early detection of EC misplacement.

Unrecognized spinal placement of an epidural catheter is a serious complication. It can cause a high/total spinal block which can lead to a catastrophic outcome.

A 37 year old woman was admitted to elective cesarian section at 39 weeks of gestation. Previous history includes an uneventful cesarian section 7 years ago. A combined spinal-epidural block in the sitting position through the L3/L4 intervertebral space using a median approach was achieved after 3 attempts by loss of resistance to normal saline. A needle-through-needle technique was performed. CSF flow was confirmed by glucose testing and 1.6ml 0,5% Bupivacaine and 2 µg sufentanyl were administered. The epidural catheter was then inserted and negative aspiration was confirmed. Due to incomplete block for surgery, 9.5mL of 2% lidocaine was injected through the epidural catheter after negative aspiration. During the following minutes, the patient gradually complained a feeling of imminent death and upper limb paresthesia, and rapidly progressed to apnea. A rapid sequence induction was immediately performed, with mechanical ventilation. A double check of the epidural catheter uncovered a positive aspiration of LCR. The cesarian section was uneventful and the patient was extubated at the end of surgery, forty minutes later. No other complications developed. She remained stable and after 4 hours both motor and sensitive blocks were fully reversed.

The most likely mechanism responsible for the high spinal block was the migration of the epidural catheter while the patient was repositioned, perhaps through the dural puncture caused by the spinal needle.

Spina bifida occulta, a relatively common neurologic anomaly (12.4 %) (1), presents challenges for neuroaxial anesthesia although, it is not a contraindication to this technique (2).

A 25-year-old woman, 39 weeks pregnant in labor was admitted in the hospital. No past medical history was described. The anesthesia team was called in as the patient was experiencing uncontrolled pain but refused the placement of an epidural catheter. During the discussion, she disclosed that she had spina bifida and believed that epidural catheter placement was contraindicated for individuals with this condition. Confirmation of spina bifida at the L5-S1 level was obtained from a CT scan in her digital records. Despite attempts to alleviate her pain with patient-controlled analgesia (PCA) with bolus of 1 ml of remifentanil (20 mcg/mL), the patient remained with bursts of pain. The PCA was stopped 20 minutes before birth however, the newborn experienced respiratory difficulties with an APGAR 6/7/8, that resolved after measures from the neonatal care.

Epidural analgesia with lumbar catheter placement is the preferred method for labor pain management, benefiting both the mother and the fetus (1). This decision should be made in line with the patient, that should be informed of the multiple techniques for labor pain control in advance. Effective communication between obstetric and anesthesia team can provide time and logistic management of the patient namely with a pre-procedural evaluation, ultrasound guidance and consideration of alternative techniques. This approach can provide better care to the patient with better satisfaction and outcomes.

Heart disease in pregnant women can be rheumatic heart disease, cardiomyopathy, and congenital heart disease. A low-dose spinal combined epidural is effective in caesarean delivery with minimal side effects and reasonable outcomes in parturients with cardiac disease. We describe the successful use of a low-dose spinal combined epidural anaesthesia in a parturient with congenital heart disease for Cesarean section.

This report describes the outcomes of each patient who underwent a low-dose spinal combined epidural for anesthesia management in 16 parturients with congenital heart disease treated at RSUD Dr. Saiful Anwar Malang.

Sixteen patients with low-dose spinal combined epidural technique (80%) were discharged from the hospital in good condition; three patients who are one patient with PDA and 2 VSD using single shoot low-dose spinal, and five patients with VSD, four patients with PDA, two patients in ASD, one patient with TOF, one patient with PPCM using a low-dose spinal combined epidural.

The low-dose spinal combined epidural is a good choice for a parturient with congenital heart disease.

Melkerson rosenthal syndrome (MRS) is a rare condition characterized by recurrent episodes of facial edema, facial paralysis and fissured tongue. The anaesthetic concerns include increased risk of difficult airway caused by airway edema. Therefore, avoidance of triggers of histaminic release and use of regional anaesthesia whenever possible should be conducted. Corticosteroids and antihistamine drugs may be administered when facing airway instrumentation. Only a few published case reports of anaesthetic management were found, hence, we present a case of labour analgesia in a patient with confirmed diagnosis.

A primiparous 28-year-old woman at term was admitted for labour induction. She had been diagnosed with MRS nine years ago and treated with oral deflazacort for two years, leading to remission ever since. Since then, mild exacerbations were resolved with topical corticotherapy. There were no known pharmacological triggers. She denied exacerbations during pregnancy. Airway examination showed no signs of difficult airway. She requested epidural analgesia, which was placed with no complications, followed by an initial bolus of 10 mL ropivacaine 0,2% and 10 mcg of sufentanil. Analgesia was maintained with 10 mL of 0,2% ropivacaine on demand.

Patient remained comfortable, hemodynamically stable, without signs or symptoms of exacerbation. Vaginal delivery occurred without complications.

This case highlights the implications of this syndrome, especially the risk of difficult airway. Epidural analgesia is possible and a good option to avoid airway interventions. A thorough and timely evaluation is essential.

Cerebral cavernous angiomas are benign vascular malformations and an important cause of intracranial hemorrhage. They may present with seizures, focal neurological defects, and headache. Although they are not uncommon with an overall incidence of 0.4%, limited reports have been documented regarding their optimal peripartum anaesthetic management.

A 31-year-old primigravida (65 kg, 155 cm) presented at 37 weeks for a scheduled caeserean section. She was a diagnosed case of an incidental cerebellar venous angioma by MRI (0.8 cm x 0.5cm). Although she presented with no persistent neurological deficit or any signs of raised ICP, it was decided not to be induced for a low Valsalva vaginal delivery to prevent straining in labor.

Effective neuraxial block was achieved with spinal with 10mg of 0.5% heavy bupivacaine and 15mcg fentanyl. Her hemodynamic parameters remained stable throughout without needing any vasopressors. After the end of surgery, she was transferred to the PACU. She recovered uneventfully and was discharged home after three days.

Antepartum anaesthetic and neurosurgical consultation is required to undertake risk/benefit planning for all high-risk parturients with intracranial pathology. The main anaesthetic goals are to maintain hemodynamic stability avoiding a hypertensive surge, rise of ICP and subsequently, risk of angioma rupture. We decided to perform spinal in view of avoiding the sympathetic response to intubation/extubation, thus achieving lesser intraoperative blood loss and providing better analgesia. Blood pressure derangements due to neuraxial-induced sympathetic blockade leading to nausea and vomiting and a subsequent rise in ICP should be carefully avoided.

Gestational thrombocytopenia (GT) occurs in 5%-10% of women during the 3rd trimester or the immediate postpartum period. Coronavirus disease 2019 (COVID-19) related thrombocytopenia (CT) occurs in 5-40% of non-pregnant patients, and there are reports of its occurrence in pregnancy. GT increases the risk of peripartum haemorrhage and epidural hematoma following neuraxial techniques.

We describe the management of a postpartum woman with CT and an epidural catheter in situ.

A 37-year-old primigravida, 37w+5d, was admitted to the labour ward. Pregnancy was uneventful and laboratory results of the admission were normal (table 1). An epidural catheter was placed for labour analgesia. Nine hours later, due to non-reassuring fetal status, an emergency C-section was performed under general anaesthesia, with an unremarkable intraoperative period. In the recovery unit, the patient started complaining of dyspnea and cough. Laboratory test results showed a positive PCR test for SARS-CoV-2 and new onset thrombocytopenia (56,000/μl). She required oxygen by nasal cannula for 48 hours and was closely monitored for the onset of neurological symptoms. The epidural catheter was removed when the platelet count became normal (72 hours later). The remaining postpartum period was uneventful.

This case emphasizes that CT may develop quickly and present before respiratory symptoms. In this case, the existence of a normal complete blood count on admission helped establish the onset of thrombocytopenia. A falling platelet count indicates a worsening of COVID, thus reinforcing the importance of close monitoring and follow-up. Other causes of thrombocytopenia, both pregnancy and non-pregnancy related should be ruled out.

Placenta percreta is a severe form of placental accretism in which the placenta penetrates the entire uterine wall and attaches to other organs, raising the risk of obstetric haemorrhage, peripartum hysterectomy, along with maternal and fetal mortality. We report a challenging case of a multidisciplinary approach to massive bleeding following a placenta percreta diagnosed during the cesarian section.

A 35-year-old, G2P1 (previous cesarean) and 30 weeks gestation pregnant woman was diagnosed with placenta percreta during an emergent cesarean under spinal anaesthesia due to imminent premature labour. General anaesthesia was performed, and as the caesarean began, a massive haemorrhage survene. The multidisciplinary team and the transfusion protocol were activated and guided by viscoelastic tests. The transfusion therapy included: 5 red blood cell transfusions (5UCE), fibrinogen (4g), tranexamic acid (2g) and crystalloids (4L). Vasopressor support under invasive monitoring (30mcg/min) and, ultimately, the hysterectomy were required to control the bleeding. A total blood loss of 2500mL was estimated.

The patient was transferred under invasive mechanical ventilation to an intensive care unit. On the third postoperative day, the patient developed a post-hysterectomy hematoma, and thromboembolism prophylaxis was not started. Two days after, she developed pulmonary thromboembolism and started anticoagulation, receiving hospital discharge on the seventh postoperative day.

Placenta percreta is a life-threatening clinical entity where multidisciplinary teamwork and a careful preoperative plan are crucial to success. Our case was handled with a prompt and effective response during an unforeseen event with success.

Rapid sequence spinal anesthesia for emergent cesarean delivery remains a controversial technique in patients with relative contraindications such as systemic infection.

A 20-year-old woman at 41 weeks of gestation was admitted due to severe labour pain and early decelerations on CTG. The patient requested epidural analgesia, which was contraindicated due to prolonged rupture of membranes and elevated inflammatory markers (leukocytes: 25000/mL, CRP: 30 mg/dL) on admission. After starting antibiotic therapy, a remifentanil perfusion was started under clinical and instrumental monitorization and titrated to 0.15 mcg/kg/min, according to institutional protocol, providing effective pain relief and stable vital signs. An hour after admission, the patient developed a placenta abrupta. She was swiftly transported to the operating theatre, where a rapid sequence spinal anesthesia was performed, providing adequate anesthesia and a timely completion of the caesarean delivery.

The child was born healthy and the patient developed no neurological complications after the procedure.

Rapid sequence spinal anesthesia may contribute to reducing the decision-to-delivery interval in patients without an epidural catheter, leading to favourable outcomes for both the mother and the neonate in challenging clinical situations. Further studies should investigate whether single puncture neuraxial techniques require antibiotic pretreatment for infection and for how long.

Lower segment caesarean section (LSCS) is a major abdominal surgery, associated with moderate to severe post-operative pain if not adequately managed. This is the second loop of the audit, with the first loop having taken place one year prior at Northwick Park Hospital Maternity Unit with the PROSPECT guidelines. Aim: - To assess pain scores and patient satisfaction in women following LSCS at Northwick Park Hospital Maternity Unit. - To document current practice of neuraxial opiate use. - To measure the compliance of post-operative analgesia prescription and administration according to the protocol. - Compare these data with the data collected in the first loop to identify areas and strategies for further improvement.

Audit registration number :- SUR.NP.22.357 Microsoft Forms-based questionnaire Consulting women 24 hr post LSCS Audit period:- 12th April 2023 to 12th May 2023 Total number:- 104 Inclusion criteria:- all women post LSCS Data collection by face-to-face consultation, assessment of anaesthetic and drug charts

88/104 patients were very satisfied with the analgesia 75/104 patients had their pain scores below 4/10 100/101 who received neuraxial blockade received dual opioids 76/104 patients received PR Diclofenac 104/104 received at least one form of analgesia 104/104 patients received their regular analgesics 7/104 patients required 2 or more rescue Sevredol

We saw a clear improvement as compared to our first phase in terms of - Use of long-lasting opioids in the neuraxial blockade - Use of TAP block for patients undergoing GA - Ensuring all the patients received their regular prescribed analgesics

Post-Puncture Headache Recurrence (PPHR) is a complication of performing neuraxial techniques. Performing a blood patch is a recognized treatment with a high success rate, however, recurrence of headaches after it has been described.

Clinical case: 33 years pregnant. Admitted for induction of labor. An epidural block was performed for labor analgesia, which complicated with accidental perforation of the dura mater with a Touhy needle. Six hours after delivery, headache typical of PPHR started, so conservative treatment was instituted. Due to the lack of symptoms improvement, a sphenopalatine block was carried out with no symptomatic improvement. For that reason, a blood patch was decided upon, resulting in complete resolution of the symptoms and the patient was discharged the following day. That night, she returned to the hospital due to a relapse of severe headache. After discussing the case with a Neurology specialist, a Magnetic Resonance Imaging performed that showed no signs of cerebral spine fluid hypotension. Conservative treatment was decided. The patient was discharged 4 days later with partial improvement of her condition.

PPHR after performing a blood patch has been described. The risks and benefits of performing a new blood patch or conservative treatment must be weighed. Before starting treatment for PPHR, it is necessary to make a differential diagnosis with other causes of headache in the puerperium after performing neuraxial techniques.

Obstetric cases account for 45% of all neuraxial blocks performed. Neurological injuries following neuraxial anaesthesia are rare. Obstetric neuropathies, by contrast, are common and often are mistakenly attributed to neuraxial intervention. Neurological issues post-partum are commonly referred to anaesthesia as a complication however are often unrelated to anaesthetic intervention. The aim of this project was to characterise potential post-anaesthetic neurological complications and their outcomes in an obstetric cohort.

All patients reported as having a potential neurological complication from January 2020 to December 2022 were identified. Potential neurological injuries were defined as motor weakness or altered sensation in any area. Identified patients’ electronic records were then reviewed to assess the nature of potential injury, management and follow up.

Approximately 18,600 neuraxial blocks occurred during the period studied. Sixty-seven potential complications were identified (Table 1). A third of potential complications were non-specific short-lived disturbances in neurological function, such as non-dermatomal numbness or paraesthesia, all of which resolved without intervention. 18% of patients had symptoms and signs consistent with cluneal nerve palsy. 21% had distinct unilateral lower limb peripheral nerve or lumbosacral plexus symptoms which were attributed to obstetric neuropathy. Of those requiring referral for further intervention, 2 required urgent, and 2 non-urgent, referral for imaging and Orthopaedic-spinal review. One required an outpatient MRI. No surgical intervention was required in any case.

Many post-partum neurological issues referred to anaesthesia are unrelated to anaesthetic intervention. The overall incidence of neurological injury after neuraxial anaesthesia is low.

Introduction: Total spinal anaesthetic failure after successful aspiration of CSF with meticulous technique and dosing is uncommon. There are no clear consensus guidelines on how to follow up this cohort of patients.

Case report: We present a case of a 34-year-old, gravida 2 para 1 patient who was posted for an elective caesarean section in view of previous LSCS. She had an uneventful caesarean section 13 years ago under spinal anaesthesia. Spinal anaesthesia was performed by an experienced anaesthetist with standard technique and dose, but complete absence of block was noted after 15 minutes. Spinal anaesthetic was repeated in the same interspace. On both occasions free flow of CSF and aspirate were confirmed, barbotage done and drug given. Both attempts resulted in complete absence of block and LSCS was done under general anaesthesia.

After a thorough review of literature, we formulated the following list of potential causes for a ‘pseudo successful lumbar puncture.’ • Congenital meningeal cysts (eg : Tarlov cyst) • Local anaesthetic resistance due to Ehlers Danlos syndrome, sodium channel mutations and scorpion bites • “Flap valve” formed during the procedure. • Prior injection of LA through an epidural catheter mimicking CSF

We feel there should be guidelines for the post anaesthetic follow-up in this cohort of patients who had a failed spinal with evident CSF flow. Further evaluation, referral to neurologist and if necessary, MRI spine should be encouraged.

We will attempt to review the pathophysiology of preeclampsia, the relevant literature and up-to-date guidelines regarding the appropriate measures for effective treatment of both preeclampsia and pulmonary edema and research the association of the aforementioned events with the newborn’s pathology.

We are going to present a singular case of a woman with preexisting, untreated, moderate hypertension before conception that developed preeclampsia during caesarian section under spinal anesthesia with acute pulmonary edema as the first presentation. The patient remained hemodynamically stable with minimal fluctuation of her blood pressure up until thirty minutes after delivery when she complained about dyspnea and severe headache with a concurrent spike in her blood pressure and auscultatory crackles in her lungs.

The patient was diagnosed early and treated successfully with diuretics, hypertensive therapy, supplementary oxygen and anti-Trendelenburg position with no further incidents until her discharge from PACU. The newborn developed ARDS minutes after birth requiring intubation and mechanical ventilation despite exhibiting no symptoms at the time of delivery.

Pulmonary edema is a rare complication of pregnancy usually associated with preeclampsia and requires the immediate intervention of the anesthesiologist team when it occurs during delivery. Preeclampsia requires vigilant monitoring even after postpartum and the contribution of different specialists to ensure a positive outcome for both the mother and the infant.

Electrical storm (ES) is a state of cardiac electrical instability characterized by multiple episodes of ventricular arrhythmias. It is a very rare condition during pregnancy, especially without a history of heart disease. We present a clinical case of a woman with a twin pregnancy who developed a very challenging and refractory ES.

A 28-year-old woman with a bicorionic/biamniotic twin pregnancy and a history of anxiety presented to our center at 32 weeks of gestation due to dysuria and diarrhea, which started one day after she began taking quetiapine. She was admitted for evaluation and started on nifedipine for tocolysis. After one hour, the patient developed polymorphic ventricular tachycardia (VT) with significant hemodynamic instability. Due to the inefficacy of pharmacological and synchronized cardioversion, an emergent cesarean section was performed. The twins were born without complications. However, she maintained the VT and was admitted to the intensive care unit. After six days of numerous attempts at synchronized cardioversion and pharmacological therapy, a successful ablation of the apical focus of the left ventricle was performed, resulting in a return to sinus rhythm.

This case occurred in a pregnant woman with no previous heart disease. Ablation was not immediately available as a specialized team was required in our department. The only way to achieve hemodynamic improvement was through the use of isoproterenol. All the other drugs and synchronized cardioversion had no significant effect. She recovered after a few weeks with no significant morbidity.

A structured, team-based management approach is paramount for these clinical cases

Cystic fibrosis (CF) is an autosomal recessive disease with predominant impact on respiratory and gastrointestinal system. Pregnant women with CF have a higher risk of complications during pregnancy and childbirth. We present a case of a successful caesarean section under spinal anaesthesia in a patient with CF with multiple comorbidities.

A 25-year-old female with cystic fibrosis in 34th week of gestation was admitted to the hospital for a planned Caesarean section due to worsening symptoms of underlying disease and general condition. The patient was hospitalized several times due to exacerbation of pulmonary symptoms and was treated with antibiotics. Other diseases include diabetes mellitus type 2, asthma, hypothyroidism, bronchiectasis, chronic colonisation with Pseudomonas aeruginosa and MRSA, celiac disease, tachyarrhythmia and a history of Clostridium difficile enterocolitis. She required continuous corticosteroid therapy, oxygen supplementation with nasal catheter, insulin, thyroid hormones supplementation, inhalations and other medications used in treatment of CF. Latest arterial blood gases were in normal ranges (PaO2 13.465 kPa, PaCo2 5.332 kPa). For C-section, a mixture of 1.9ml 0.5% hyperbaric bupivacaine and 0.4ml fentanyl, based on a patent’s height and weight, was applied intrathecally at the L2-L3 level with 27G needle.

The operation was successful and a healthy newborn was delivered. The patient’s respiratory function was not impaired and she was discharged to the PACU with stable vital signs and no need for intensive care monitoring.

In conclusion, we believe that a spinal anaesthesia with “heavy” bupivacaine is good anaesthetic technique for pregnant women with severe cystic fibrosis.

Multiple Sclerosis is an autoimmune disease characterized by chronic inflammation with subsequent demyelination with axonal loss, affecting approximately 1 million adults with two thirds of them being women in the child-bearing age. This study aimed to present our experience with anaesthetic management of parturients with multiple sclerosis and to assess the association between neuraxial anaesthesia and the occurrence of relapse during the first year post-partum.

In this prospective study, ten cases of women with a diagnosis of multiple sclerosis were enrolled in this study. These parturients were subjected to spinal anaesthesia for the purposes of caesarean delivery between 2019 and 2021. Demographic, anaesthetic and obstetric characteristics, occurrence and number of relapses during the first year post-partum were recorded.

None of the patients reviewed relapsed during the first year after delivery.

Despite theoretical concerns with regards to spinal anaesthesia and multiple sclerosis because of potential exposure of demyelinated areas of the spinal cord to the neurotoxic effects of local anaesthetics in the cerebrospinal fluid, our data comply with current opinion that spinal anaesthesia could also be a safe alternative for pregnant women with multiple sclerosis.

Administration of epidural analgesia in a patient with prior spinal surgery is a unique challenge. There may be difficulty of locating epidural space, interference with local anaesthetic spread, and accidental dural puncture. Also, appropriate deliver position is known as one of the key of successful vaginal delivery. It may be difficullt for those who has disability of lower extremity.

Written informed consent was obtained from the patient for presentation. A 29-year-old nulliparous woman was sent for evaluation of epidural analgesia use in 35th gestational weeks. She took osseointegration limb surgery in infancy, and T3-L1 posterior interbody fusion and L1-L3 lateral interbody fusion at age 13 and 15. MRI showed that lumber epidural space was intact. There were no neurologic impairments of both upper and lower extremities and she assumed a delivery position with her artificial leg. After review of these evaluation, she was offered labor epidural anaesthesia.

She presented at 39 weeks in labor. Epidural anaesthesia was successfully placed at L3/4. A total dose of 5.7ml of 0.2% levobupivacaine and 25 μg of fentanyl were injected in increments, and the patient reported Numerical Rating Scale 0. With using programmed intermittent epidural bolus, epidural anaesthesia provided satisfactory analgesia. She delivered a healthy baby vaginally with no adverse events.

Although Labor epidural anaesthesia is known to be technically difficult in patients with prior spinal surgery, neuraxial anaesthesia can be performed safely and effectively in this case. An appropriate pre-labor assessment is needed for the patients with those difficulties.

An 18-year-old female,presented to labour ward, G2P0 36+6 weeks pregnant,with history of cardiac transplant for idiopathic dilated cardiomyopathy diagnosed at age of 13 and transplanted at age 13,with dual chamber pacemaker, with good exercise tolerance.Due to worsening acute kidney injury,secondary to a combination of Tacrolimus and obstructive hydro nephrosis of the right kidney,urgent category 2 caesarean section delivery was needed to avoid sepsis.

Prior to theatre,pacemaker was checked,preoperative ECG showed a pacemaker dependant rhythm and USS of renal tract showed a moderate hydronephrosis of right kidney.Preoperative potassium was raised, treated with a dextrose-insulin infusion.Irradiated blood was crossmatched. Two wide bore cannulas and arterial line were inserted. Patient was consented and a spinal anaesthetic was administered.Intraoperative cell salvage was used due to anaemia in pregnancy. Postoperatively, patient was managed in labour ward HDU with strict fluid balance.Kidney functions gradually improved and Tacrolimus levels was monitored.

Preconception councelling is paramount.pregnancy should be delayed at least 1 year after a heart transplant.Higher incidence of pre-eclampsia,eclampsia and gestational diabetes have been reported.Monitoring of immunosuppressant levels is vital.

Pregnancy after heart transplantation brings many new considerations to the anaesthetist especially as this is a rare occurrence! this case report shows the importance of a multidisciplinary team approach whilst keeping the patient at the centre of combined decision making. Patients require a tailored anaesthetic plan and careful perioperative preparation to ensure safe patient care. Punnoose, L.R. et al. (2020) “Pregnancy outcomes in heart transplant recipients,” The Journal of Heart and Lung Transplantation, 39(5), pp. 473–480.

We present the case of a 39 weeks parturient, scheduled to an elective c-section due to a myocarditis caused by COVID-19 mRNA vaccination.

The myocarditis had developed following her second COVID-19 vaccine during her 29th week of gestation. Her prior history included gestational diabetes, and smoking. She presented with retrosternal pain and nausea, increased troponin, leucocytosis, infra-PR and diffuse ST elevation. Her echocardiogram had an ejection fraction of 55% with apical and inferolateral hypokinesia but the coronarography excluded active coronary disease. She was discharged after 4 days with resolution of symptoms and medicated. After a careful multidisciplinary assessment, an elective c-section at term was decided.

Myocarditis following COVID-19 vaccination is a rare complication of mRNA vaccines. Because pregnant people are at increased risk of severe disease and obstetrics complications, their vaccination is considered effective and safe. For parturients with myocarditis, caesarean delivery under epidural anaesthesia is considered to be a safer alternative. It avoids the stress of laryngoscopy, tracheal intubation on a potential difficult airway, and the potential problems of mechanical ventilation. In this case, due to a faulty syringe, we could not estimate how much dose of bupivacaine and sufentanil had been injected to the subarachnoid space. Despite careful administration of epidural ropivacaine, a satisfactory blockade could not be obtained. Carefully titrated general anaesthesia had to be induced to avoid cardiovascular depression. The surgery carried out uneventfully, and a healthy new-born was delivered.

This case shows that despite meticulous technique, unsatisfactory blocks can still occur due to material defect.

Acute post-operative pain management can be challenging due to subjective nature of pain and difficulty in assessing in patients who are sedated after general anesthesia. This study aimed to assess postoperative pain by use of both subjective and objective parameters.

Patients aged 18-60 years, ASA I/II and posted for elective lower abdominal surgery of atleast 4 hours were included. Consent refusal, emergency surgery, history of chronic pain was the exclusion criteria. Subjective markers (VAS, satisfaction score) and objective marker (pupil diameter) were recorded at baseline and at consecutive hours postoperatively (6, 24, 48 hours). Objective marker CNTN1 was measured at baseline and at 48 hours postoperatively.

After ethical approval, 40 patients were studied. Mean±SD age was 46.13±11.43 years. VAS score postoperatively at 6, 24 and 48 hours were 3.72±0.87, 3.48±0.87, 1.48±0.50 respectively, showing significant decline at all time intervals. Satisfaction score also improved significantly at 6, 24, 48hours. Mean ± SD of pupil diameter at baseline, 6, 24 and 48hours postoperatively was 4.64±0.94, 5.27±0.86, 5.08±0.77, 4.6±0.89 respectively. CNTN1 at baseline and at 48hours was 0.21±0.026 and 0.19±0.028. We found positive and statistically significant correlation between VAS score and pupil diameter at all time intervals.

VAS score correlated well with pupillary diameter. Thus pupillary diameter can be chosen as an objective measurement of postoperative pain severity.

In Outpatient Surgery (OS), post-discharge follow-up calls are essential for identifying complications, including pain. Currently, there is a lack of scientific evidence to support the validation of follow-up protocols adjusted to patients’ specificities. This study aims to develop an individualized follow-up model.

We performed a retrospective, single-center study, including patients undergoing OS at a tertiary hospital in Portugal, for three months. Follow-up calls were performed on the 7th and 14th days after discharge. Were analyzed sex, age, surgical specialty, anesthetic technique, American Society of Anesthesiologists physical status classification, surgery duration, and complications. A binary logistic regression was adjusted for the complications detected in each call.

785 and 741 answered the 1st and 2nd follow-up calls, respectively. Complications were reported in 47.1% (n=370) and 29.8% (n=221) of these calls, respectively, with pain having the highest incidence rate: 44.7% in the 1st call, 26.6% in the 2nd (Table 1). The type of anesthesia, surgical specialty, and, in the 1st call, surgery duration were independent risk factors for complications (p≤0.004). A model that predicts the detection of complications in each call was created (Image 1).

This study recognized the influence of several variables in the incidence of post-discharge complications and emphasized that pain was the most frequently reported complication. According to it, the type of anesthesia, surgical specialty, and surgery duration should be considered when establishing individualized follow-up plans. In our reality, no follow-up calls are routinely performed after the 7th day, meaning some patients probably should be accompanied for a longer period.

Due to closure and redirection of several vascular units in our area and our expertise in endovascular surgery, we experienced a large increase in our vascular surgery population in 2018. This came with high levels of acute pain on the ward. In 2019-2020 we audited anaesthetic and analgesic techniques via questionnaire. Regardless of anaesthetic or single shot nerve block, our rate of severe pain 24 hours after lower limb amputation was extremely high at 76%. We aim to eliminate severe(7-10) pain and have 80% of patients with good pain management(score 0-3) in order to start physiotherapy on day 1 postop.

We recommended higher oramorph doses, anticipatory morphine prescribing, routine acute pain nurse review day 1 postop and routine surgical placement of sciatic or tibial nerve catheters with 10ml/h 0.125% levobupivacaine via epidural set and pain bomb. We also switched to an electronic notes system, where pain score 0-10 is regularly recorded with other observations. This year we used this to retrospectively audit pain in 108 patients (after 10 exclusions for lack of data).

95 had nerve catheters, only 6(7.41%) had severe(7-10) pain and 71(74.74%) had good(0-3) pain control. 13 patients did not receive nerve catheters but pain management had still improved, with 2(15.38%) in severe pain and 7(53.85%) with good pain control.

The difference between patients with and without nerve catheters did not reach statistical significance, but we continue to drive toward our short term goals and will later compare before and after rates of phantom limb pain.

TENS is a commonly used adjunctive therapy in chronic pain. The aim of this audit is to understand whether our use of TENS in acute pain setting is effective in achieving pain relief,and whether this reduces opioid doses.

A total of 15 patients were surveyed by the acute pain team, all of whom received TENS as an adjunctive, post-operative pain therapy. They were asked to rate the pain score as mild, moderate or severe at baseline, then for each day they received TENS therapy. They were also asked whether they felt TENS improve the quality of sleep, and their ability to mobilise.This audit was approved by local ethics committee.

13 out of 15 patients responded and completed the survey. Mean baseline pain score was 1.62 at rest, and two on movement. This reduced to one at rest and 1.46 on movement with the use of TENS. Where documented six out of nine patients had a reduction in the analgesic use. One out of six patients had an improvement in sleep with the use of TENS.Four out of seven patients felt that TENS improved their functional ability.

TENS was associated with a reduction in pain scores in the acute pain. The data collected may be confounded by the involvement of the acute pain team which would also be reasonably expected to reduce pain scores. What we have shown in this audit is that TENS can be used in the acute pain setting as part of a more comprehensive acute pain management.

Surgery is a risk factor for persistent postoperative opioid use and pre-operative opioid use is associated with an increased risk of perioperative complications. Perioperative opioid stewardship (judicious use of opioids to treat surgical pain) is increasingly regarded as a solution to this problem. However, healthcare professionals lack a structured curriculum to develop the skills needed for competent opioid management. To address this, we developed a learning platform for a global, multidisciplinary audience.

We describe the process and challenges in developing an innovative educational tool for perioperative opioid stewardship. The Massive Open Online Course (MOOC) concept has grown exponentially in availability and popularity since 2012. Delivered completely online, free to access and open to all, MOOCs defy traditional classroom limits, enabling education to be delivered at scale. A collaborative approach with an international, multidisciplinary faculty was required to maximise accessibility to this educational resource.

A three-week online, open-access, interactive course has been developed in partnership with University College London (UCL) Hospitals, UCL and FutureLearn. Focusing on opioid pharmacology, perioperative use of opioids and opioid stewardship, it brings together an international, multidisciplinary faculty with the input of patient experts. Over three weeks, participants will spend 3-4 hours per week learning via a mixture of written and audiovisual modalities: peer-reviewed articles, video interviews with clinicians and patients, interactive case discussions and quizzes. The MOOC is due to launch in the fourth quarter of 2023.

A MOOC is an innovative approach to improve the understanding and implementation of perioperative opioid stewardship and transform practice.

Total scapulectomy involves severe postoperative pain and requires continuous regional anaesthesia for its control. Our aim is to review the anaesthetic strategy and postoperative pain in patients undergoing this surgery.

Our retrospective observational descriptive study reviewed the anaesthetic techniques and postoperative pain control (NPRS at rest and at movement) in 5 patients undergoing total scapulectomy and reconstruction with scapular prosthesis between 2014-2022 at our hospital. Ethics committee approval was requested (IIBSP-ARC-2023-71). Quantitative variables are presented as median (range).

All patients received a continuous interscalene block (CIB) (table 1). Three patients received another associated technique: single-shot paravertebral block (CIB+PVB)(n=1), paravertebral with catheter (CIB+ CPVB)(n=1) or superficial cervical plexus block (CIB+ SCB)(n=1). Surgical time was 4h (3-5), bleeding around 1L (0.5-1.5). All presented mild postoperative pain at rest (NPRS<3), except one patient (CIB+PRV) who presented severe pain (NPRS=9) due to failed CIB. When moving, all patients presented moderate pain (NPRS 6-8) requiring opioid rescue, except the patient with CIB+CPVB, who registered NPRS 1 at movement and NPRS 0 at rest. Morphine rescues were higher in patients with isolated CIB. Interscalene and paravertebral catheter were removed after 4 (2-7) and 7 days, respectively. Four patients needed blood transfusion. The ICU stay was 1 day (1-3) and hospital LOS 8 days (8-11).

CIB associated to CPVB achieve the best analgesic results at rest and movement. Catheter placement entails greater technical difficulty for the benefit of better analgesic quality in the perioperative period, compared to isolated CIB, without increasing hospitalization days or postoperative complications.

The Analgesia Nociception Index (ANI) has been useful for pain intensity assessment in the operative context [1,2,3]. This study analysed ANI for pain prediction in Post Anesthesia Care Unit (PACU).

Electrocardiogram (ECG) recordings from 30 patients (ages 23 to 84, 14 female) in PACU were considered, with a total of 27 valid pain reports registered. The ANI series were estimated from the ECG and 11 statistical features were computed from paired 5-minute ANI, before and after the pain report. Statistical tests revealed significant differences in Median, Maximum, Mean, and Average Power regarding pain and no-pain periods. Machine learning models were trained using the K-Nearest Neighbors (KNN) and Decision Tree (DT) algorithms for binary pain prediction, using: (1) DS-A: 11 features; (2) DS-S: four differentiating and selected features.

The KNN models presented an accuracy of 0.74. Although the model with fewer features is computationally more efficient, the dataset (2) model presented a greater F1-score and sensitivity. Additionally, all models presented a greater rate of false positives (false alarms) than false negatives (missed detections).

These results can be extremely relevant for the PACU context because there is a higher probability of falsely alarming pain situations than of missing pain occurrences. Regarding a support decision system, the ultimate decision of pain relief strategy relies on the clinician, which in case of a suggestion of the patient being in pain will consider other vital signals to support the decision, hindering the neglection of real pain situations [4].

BACKGROUND: Some patients undergoing laparoscopic nephrectomy still describe severe postoperative pain. The aim of the study is to assess whether serratus-intercostal block (SIPB) is equal or superior to posterior quadratus lumborum block (QL2) in terms of pain control and quality of postoperative recovery compared with a control group.

This blinded randomised controlled study, was approved and registered. The calculated sample size was 126 patients undergoing laparoscopic nephrectomy. The grupe SIPB were patients who received serratus-intercostal plane block at the eighth rib as analgesic technique , QL2 group those who received quadratus lumborum block and control group those who did not receive regional technique. Pain scores on the numeric rating scale (NRS) and the quality of postoperative recovery (QoR-15) were assessed. Intraoperative fentanyl and postoperative morphine consumption were collected as secondary aims.

Descriptive statistical results of 118 patients show similar intraoperative fentanyl consumption in both groups (SIPB 363µ+147; QL2 327µ+112) and postoperative morphine consumption (SIPB 3.43 mg + 5.9; QL2 3.5 mg + 5.5), (p 0.604). Also no differences were found in QoR15 (SIPB 107 + 17; QL2 107 + 16), nor in pain control NRS 0 (SIPB 1.4; QL2 0.9), NRS 12 (SIPB 3; QL2 2), NRS 24 (SIPB 1.6; QL2 1.55). Comparing the regional technique groups to the control did show statistically differences (p=0.05) in intraoperative fentanyl consumption.

The SIPB and QL 2 have shown an adequate postoperative pain control, achieving good quality of recovery and low opioid consumption, especially when compared with the control group.

We retrospectively evaluated the clinical analgesia efficacy in multimodal analgesic techniques combining a single peripheral nerve block and a single acetaminophen administration.

A retrospective observational study approved by an ethics committee at a single-center university hospital, 273 lower extremity surgeries performed between April 2020, and April 2021, were conducted. Subjects were maintained by general anesthesia with several US-guided nerve blocks. Pain score (VAS value ≥five) within 2 hours was defined as block failure (F group: 12.1%). 240 patients in the successful nerve block group (group S) were classified into acetaminophen non-treated group (group A) and acetaminophen treated group (group B) to evaluate their clinical efficacy. The primary endpoints were VAS at 0, 2, 6, 12, and 24 hours, the number of patients with VAS values ≥ five within 6 and 24 hours, rescue medications, PONV cases. Statistical analysis using the χ-square , T and Mann-Whitney U test and p-value<0.05 was considered statistically significant.

No background difference between Group A and B. Acetaminophen-related postoperative pain in 6 hours (7 patients (11.3%) in Group A and 7 patients (3.9%) in Group B; P=0.03). No differences were noted in rescue medications, or PONV counts between A and B. Block failure related to higher VAS through the postoperative course and rescue medications.

A lower VAS score within 2 hours postoperatively was associated with lower VAS values up to 24 hours and a lower number of rescue medications. A single intraoperative acetaminophen regimen with nerve block associated with lower VAS values in 6 hours postoperatively.

Patients after shoulder arthroplasty report moderate to severe pain. A unique analgesic technique is the insertion of the stimulating catheter in the perineural space. The goal was to assess the effectiveness of perineural block using an N. suprascapularis stimulating catheter against local anaesthetic administration following shoulder arthroplasty.

This prospective study was conducted at Hospital of Traumatology and Orthopaedics in Riga, Latvia from May to December 2022. The study involved 10 individuals who had a stimulating catheter placed near the N. suprascapularis. The treatment group received two 10-minute sessions of nerve stimulation in the PACU. Ropivacaine injections were administered to the control group using a catheter. The Analgesia Nociception Index (ANI) - instantaneous (ANIi) and mean (ANIm) - was employed for the assessment of pain. Scale from 0 to 100, where 100 represents total analgesia and the dominance of the sympathetic nervous system, and 0 represents the utmost possible nociception.

After stimulation, the treatment group's mean values were as follows: ANIm = 62.20 and ANIi = 61 before movement; ANIm = 68.80 and ANIi = 70 after shoulder movement. The mean values in the control group were ANIm - 64.60 and ANIi - 64.20. ANI measures were also compared to pharmaceutical therapy; in neither case, stimulation during rest or after movement, was found to be statistically significant. NRS were compared similarly in both groups, there was no statistically significant connection.

Both methods are equally effective at reducing pain. Thorough investigation of nerve stimulation technique would require additional study.

Suitable scores can determine the anxiety and pain perception of inpatients over the perioperative period. Studies have shown that the Numeric Rating Scale and the State-Trait Anxiety Inventory are validated scores for measuring pain and anxiety. The aim was to find out whether the perioperative pain in trauma patients can be determined using pain and anxiety scores. It was also interesting to what extent preoperative anxiety influenced perioperative pain.

Between December 2021 and May 2022, 40 patients where asked for a questionnaire at three points in time (pre-, intra- and postoperative) in which they stated their current pain and anxiety levels. Statistical multivariate analysis of variance with repeated measures was performed using data base Statistical Package for the Social Sciences (SPSS).

The results showed that the two parameters fear and pain influence each other during the hospital stay. This also corresponds to the statements from some other studies that determined the perception of fear and pain using measuring instruments. Patients were generally anxious about the prospective surgery and pain perception decreased over the perioperative period.

All in all, the participants in the survey were anxious and sensitive to pain on average. This can be explained by the great communication between medical staff and the patient during the hospitalization. The use of the measuring instruments NRS and STAI was also probably suitable for everyday clinical practice and should be used for sustained use in order to achieve the best possible result for risk patients.

A 65 year-old male, ASA III with a medical history of etilism, hepatic fibrosis, COPD and acquired haemophilia A presented for a pylorus preserving pancreatoduodenectomy via bilateral subcostal incision. Directly before the surgery, the factor VIII level was not sufficient (only 32%) and based on the recommendation of haematologists the patient could not receive any NSAID or Salycilate. After an uneventful surgery he was transported to the intensive care unit (ICU) in intubated state. During the surgery he hasn’t received any analgesics besides total amount of 150 mcg Fentanyl.

In order to ensure adequate analgesia bilateral external oblique intercostal (EOI) catheter were placed under ultrasound guidance at the ICU, under coagulation factor protection. Once loaded with 20-20 mL of bupivacain 0.2% patient was successfully extubated with 1/10 of VAS pain score. Continuous blocks were accomplished by intermittent boluses in every 12 hours. Sensory deficit (T7-T10) was detected by pinprick test over the upper quadrants of the abdomen. There was no need to apply any additional analgesics. We have prepared a morphine PCA pump, however the patient didn’t use it once. Two hours after the extubation he was sitting in the bed without any discomfort. The patient was released from the ICU on the first postoperative day. The catheters were removed on the 4th day.

The applied regional technique resulted in an effective and safe analgesia judged by low pain scores and early mobilization.

EOI catheters provided efficient pain relieve after a pancreatic surgery via bilateral subcostal incision.

Colorectal surgery is the main treatment for acute abdominal obstruction, although postoperative pain management is generally inadequate in most patients. It may require large amounts of opioids. This study aimes to evaluate the efficacy of bilateral ultrasound-guided mid-point transverse process to pleura block (MPT-B) in laparotomic surgery, specifically for sigmoid resection.

The procedure is carried out at the San Salvatore hospital in L'Aquila. The patient undergoing colorectal surgery receives general anesthesia with preoperative bilateral ultrasound-guided mid-point transverse process to pleura block using 20ml of 0.25% levobupivacaine + dexamethasone 4mg bilaterally. Intraoperatively, intravenous low dose Remifentanil (0.6 ng/ml in TCI mode), paracetamolo 1gr and Ketorolac 30 mg are administered as part of multimodal analgesia. To complete the post-operative analgesia, Morphine 5 mg and Ondansetron 8 mg are given after waking up. During the post-operative hospitalization, therapy with Contramal 50mg x 3/day is set up for the first 5 days. Data on intraoperative and postoperative analgesic effects and the effect on recanalization after surgery are recorded.

During surgery, the patient maintaines hemodynamic stability (PA= 110/60, FC=60 bpm); after waking up NRS=0, in the following 5 days NRS< 3; recanalization on the ninth postoperative day.

This case report suggests that, as part of multimodal analgesia, bilateral ultrasound-guided MPT-B after induction may reduce postoperative pain and opioid consumption in patients undergoing laparotomic colorectal surgery.

Local anaesthetic (LA) is an important component in perioperative pain management for knee arthroplasty. It ensures early ambulation, decreased length of stay (LOS), and increased patient satisfaction. Current strategies include surgical infiltration of LA, and ultrasound guided LA infiltration by the anaesthetist, both with limited duration of benefit. Liposomal bupivacaine (Exparel®) is a long-acting LA preparation. We aimed to compare patient outcomes using liposomal bupivacaine with bupivacaine in a sequential prospective cohort study.

50 patients undergoing knee arthroplasty were included. All patients received opioid-free spinal anaesthetic with hyperbaric bupivacaine 0.5%. Ultrasound guided multi-quadrant infiltration of the thigh and knee using a specified combination of peripheral nerve and fascial plane blocks was performed by the anaesthetists prior to surgery. Group A received bupivacaine and group B received liposomal bupivacaine. No surgical LA infiltration was done. The same anaesthetist and surgeon treated all patients. Patients were given standardised intraoperative co-analgesics.

The baseline demographics between both groups, including age, gender, ASA grade and type of surgery were comparable. There was a significantly lower median length of stay for the liposomal bupivacaine group (26:45 [IQR 22:57, 33:20]) compared to the bupivicaine group (70:21 [IQR 46:02,99:03]). The liposomal bupivacaine group also had a significantly lower 24 and 48 hour mean opioid consumption.

Ultrasound guided multi-quadrant liposomal bupivacaine infiltration is better in providing decreased length of stay, and decreased postoperative opioid consumption than standard bupivacaine in knee arthroplasty.

Managing postoperative pain after an open hepatobiliary surgery often presents a challenge. Use of regional anesthetic techniques is common to reduce opioid consumption and its associated side effects. Thoracic epidural analgesia is considered to be the gold standard for this type of surgery, however, it might be contraindicated due to abnormal coagulation, patient refusal, etc. In this study we evaluated the efficacy of continuous bilateral erector spinae block (ESPB) in this setting.

ESPB was performed in 10 adult patients scheduled for open hepatobiliary surgery in whom thoracic epidural was contraindicated due to abnormal coagulation profile or patient refusal. Procedures included Liver-Lobectomy, Hepato-pancreato-biliary, Whipple and exploratory laparotomy. ESP catheters were inserted under US guidance at the level of T5-T6. At the conclusion of surgery, patients received a bolus of 10ml of 0.25% bupivacaine into each ESP catheter followed by a continuous infusion of 0.1% bupivacaine at 12-16mL/h into both catheters. Patients also received non-opioids around the clock for multimodal pain control. We used the maximal VAS score in every 8 hours for the whole duration of infusion which varied and opioid consumption was monitored.

Patient demographics, type of surgery, contraindication for thoracic epidural, VAS pain scores taken, 48 postoperative hour opioid consumption as well as duration of ESP are shown in Table-1. All patients had successful placement of ESP catheters, no complications were noted. Pain scores were markedly low as well as opioid requirement.

Continuous ESPB is a feasible and effective technique for providing analgesia following major open abdominal surgery.

Epidural analgesia is widely used, providing effective pain control, facilitating mobilization and recovery of gut function. Although often safe, we present the case of a rare, potentially hazardous complication of this technique.

We report the case of a 75 year-old male who underwent right hemicolectomy under combined anesthesia. Epidural space was identified at T9-T10 level using air loss of resistance (LOR) technique and was subsequently tested using 2% lidocaine after negative catheter aspiration. Catheter placement and testing were unremarkable. During surgery, several 0.2% ropivacaine boluses were administred. Afterwards the patient reported controlled pain, without paresthesia or motor block. A perfusion of 0.15% ropivacaine and sufentanil was started and he was later transferred to the ward.

Six hours after transfer, there was a new onset of lower limb paralysis, without hemodynamic instability. Epidural perfusion was discontinued and soon after the patient had regained motor function. Aspiration of the catheter revealed clear fluid, positive for glucose, further pointing to intrathecal displacement. The catheter was removed and conventional analgesia was adjusted. Afterwards, the patient reported adequate pain control without other complaints

Although rare, anesthesiologists must be aware of this risk. Inadvertent subarachnoid administration can result in hemodynamic instability, high or complete block and death. The reasons for catheter migration are often unknown. It's likely that an inadvertent tearing of the dura occured and remained undetected despite using air for LOR technique. The role and timing of catheter testing are also debatable, as inadvertent intrathecal administration cannot be safely excluded if delayed migration occurs.

The main barrier preventing optimal pain management is the inability to identify and manage patients at elevated risk of significant pain in a timely manner, thereby compounding pain-related morbidity. Our aim was to develop a predictive model for pain score at postoperative 13-36th hours by analysing data from our centralized enterprise analytic platform (eHIntS).

We analysed postoperative data retrieved from eHIntS in 667 patients between January to July 2020, comprising demographic, type of admission, method of surgery (minimally invasive/ open), duration of surgery, procedure code, pain scores at PACU, postoperative pain scores at 0-12th hours (at rest, on movement), number of analgesia attempts at postoperative 12th hour, and delivered analgesia at postoperative 12th hour.

A total of 102 (15.3%) patients had at least one pain score of >3 at postoperative 13-36th hours, with average and maximum pain score of 2.4 (SD 0.9) and 5.0 (SD 1.4), as compared with those having pain scores 0-3 at postoperative 13-36th hours (average: 1.3 (SD 0.6); maximum: 2.4 (SD 0.9)). The multivariable model showed that Malay race as compared with Chinese, having ovarian surgery, increased PCA morphine dose at 12th hour, and having higher maximum pain score at movement at postoperative 0-12th hours were independently associated with maximum pain score on movement at postoperative 13-36th hours >3 (significant pain), with an AUC of 0.731.

This model needs to be verified and validated in a larger and more diverse dataset to increase the predictive power of the model.

There are several methods for pain control in hip fracture patients. Recently, a pericapsular nerve group block was introduced. This block is very effective for pain control in hip fracture patients, and there is a report that it is very effective for pain control after surgery, especially in the case of continuous pericapsular nerve group blocks. We would like to discuss a more effective and accurate way to perform the pericapsular nerve group block.

Two cases were administered. Both cases were hip fracture patients and ultrasound-guided continuous pericapsular nerve group block was performed. We also checked the fluoroscopic image using a contrast medium to recheck how the drug spreads and to confirm the appropriate position of the catheter. Postoperative pain was confirmed by a numerical rating scale, and complications such as motor weakness were also checked.

In both cases, low NRS was checked after surgery, and no complications occurred.

If it is confirmed that the drug spreads well between the psoas tendon and the pubic ramus and the space between the psoas tendon and the pubic ramus is widened when injecting the drug, it can be considered an effective block.

Laparoscopic cholecystectomy can cause moderate to severe postoperative pain. With the somatic component of pain being more dominant, multimodal analgesic approaches including fascial plane blocks have been employed. The Erector Spinae Plane (ESP) block can alleviate postoperative pain, but its use may be limited due to application challenges and potential complications. As an easily applicable alternative, the Rectus Sheath Block (RSB), that provides comprehensive analgesia in the periumbilical region has been shown to improve postoperative pain after various laparoscopic abdominal surgeries. We hypothesized that RSB could provide postoperative analgesia comparable to the ESP block in patients undergoing laparoscopic cholecystectomy.

After written consent, this study enrolled ASA Score I-II patients aged 18-75 undergoing laparoscopic cholecystectomy. Patients were randomized in a 1:1 ratio to either ultrasound-guided ESP block (ESP group) or RSB (RSB group). The primary outcome was opioid consumption within the first 24 hours following surgery. The mean difference between the groups was compared against a non-inferiority margin of -2. Secondary outcomes were rescue analgesia in PACU, VAS scores, and postoperative shoulder pain.

Preliminary analysis was conducted on 44 patients (ESP group: n=24; RSB group: n=20). The difference between cumulative mean morphine consumption of the ESP (6.29±1.7 mg) and RSB (6.60±3.4 mg) groups was 0.31 mg (95% CI -1.64 to 1.02; p=0.35), establishing the non-inferiority of RSB. There were no clinically meaningful differences in secondary outcomes between the groups.

This study demonstrates that RSB offers non-inferior postoperative analgesia compared with an ESP block in the first 24 hours following laparoscopic cholecystectomy.

Acute pain management in the postoperative lung transplant patient is crucial for reasons including facilitating deep breathing, coughing and also graft expansion therefore helping to avoid atelectasis, pneumonia and indeed possible graft failure [1]. Whilst the accepted gold standard for postoperative analgesia is a thoracic epidural, there are limited non-opioid management options when this fails [2]. Here, we report a novel description of an erector spinae plane (ESP) catheter as rescue analgesia following failed thoracic epidurals for a patient that underwent a single lung transplant.

Case report: A 50-year-old female, via a right sided posterolateral thoracotomy incision, underwent a largely uneventful single lung transplant for familial idiopathic pulmonary fibrosis. Following transfer to the intensive care unit, a thoracic epidural was sited at T4/5 and commenced. Once extubated, the anaesthesia was only unilaterally covering the left, non-operative side. The patient, despite troubleshooting management, described 10/10 intensity of pain and so the epidural was resited at T5/6. Unfortunately, the block remained contralateral. As rescue analgesia, an ESP catheter was done to demonstrable efficacy of an improved ability to cough and a pain score down to 4/10.

The patient continued to receive top-ups for 5 days postoperatively twice a day during which she successfully stepped down to the ward.

This case report demonstrates that ESP regional anaesthesia was effective as rescue analgesia in a patient where optimal respiratory mechanics were vital. We are now developing a protocol for ESP catheters as a rescue technique and also when epidurals are contraindicated.

The erector spinae plane block (ESP), was described in 2016. ESP block technique involves ultrasound-guided injection of volume of local anesthetic into the fascial plane between the tips of the vertebral transverse processes and erector spinae muscle. Local anesthetic spreads over 3–6 vertebral levels in a craniocaudal direction. Snapping scapula or scapulothoracic syndrome occurs due to disruption of the smooth gliding motion between scapula and thoracic cage. It can be chronic and very disabling for patients. The patient population is commonly young and active presented with pain in the scapulothoracic area aggravated by overhead and repetitive shoulder movements.

Women, 54 yo no past medical history, more than 8 months suffering right disabling scapula pain and clicking in the superior medial border of the scapula. No good results to non-operative management. VAS 9/10. Positive response to corticosteroid and local anesthetic injection. Was programmed for scapulothoracic arthroscopy under general anesthesia “chicken wing” position adding preoperative ESP block T4 for multimodal analgesia with 0.25% 25ml Levobupivacaine and dexamethasone 4mg.

VAS was recorded in time1 (1h postsurgery in PACU) 1/10, time2 (6h postsurgery) 1/10 and time3 (20h postsurgery, before discharche) 3/10. Three months later patient showed improvement in VAS versus preoperative situation and also in quality and range of movement.

We can conclude that in this patient adding to common 1st step intravenous analgesia ESP block, was a good option in terms of quality of analgesia and patient comfort without complications, but is necessary studies to recommend ESP block for this surgeries.

In patients undergoing liver transplantation, postoperative pain control can be challenging since a neuraxial block is contraindicated with ongoing coagulopathy. This led us to investigate the utility of ultrasound-guided external oblique intercostal (EOI) blocks in this patient population. Local anesthetic is injected in the fascial plane between the external oblique and intercostal muscle at the T6 and T8 levels, bilaterally, for somatic coverage of the “chevron” incision. Here, we present a small comparative case series.

This is a retrospective chart review comparing the postoperative opioid utilization of five patients with and without the EOI block.

The average oral morphine equivalents (OME) for POD 0, 1, 2, and 3 were 39mg, 70.5mg, 28.4mg, and 12.3mg in the EOI group and 71.8mg, 109.1mg, 85.5mg, and 53.5mg in the control group (table1)

30ml of 0.25% bupivacaine mixed with 20ml of liposomal bupivacaine was used and 12.5ml of this mixture was injected at each level. The average OME for each postoperative day was higher in the control group compared to the EOI group. The average OME values in the control group were close to double on POD 0 and 1 and more than doubled on POD 2 and 3 compared to EOI group. The EOI block made a clinically significant difference in our patients’ opioid usage and overall satisfaction. The EOI block is superficial with reliable sonoanatomy and can be performed in the supine position without interfering with the surgical incision. Most importantly it can be performed in liver transplant patients with ongoing coagulopathy.

Rising oropharyngeal cancer among men and women is a documented public health concern. Surgical treatment and post-surgical care of these patients are very challenging and among them odynophagia in the first 2 weeks after surgery is highly concerning. In addition to suffering that is caused by pain, poor oral intake and hence inability to take oral pain medications keeps these patients bound to hospital and is the cause of readmission and Emergency room visits during 1st 2 weeks after surgery. The goal of this study is to examine feasibility and efficacy of utilizing continuous infusion of local anesthetics to lower cervical sympathetic plexus (Stellate ganglion) for treating acute postoperative pain in patients undergoing TORS for treatment of HNC.

Post induction catheter placement of Stellate ganglion and infusion of local anesthetics for up to 2 weeks in 45 patients underwent TORS for oropharyngeal tumor resection. Results compared with historical data, 32 patients.

Patients who received a SGB had a statistically significant reduction in MME on POD 0, 2 and 3. MME use in SGB group was lower on POD 1 as well, however this did not reach statistical significance. There were no statistically significant differences in MME use between the two grousp beyond POD3 and there were no statistically significant differences in PONV or average VAS pain scores between the two groups

It is feasible and somewhat effective to use SGB block for treatment of acute pain after oropharyngeal tumor resection. No complication was noticed directly or indirectly related to SGB.

Using the regional anesthesia with GA in some surgeries has many benefits including but not limited to reducing the use of intra-operative and postoperative narcotics

53 years old female patient presented to our anesthesia clinic for abdominoplasty and Liposuctions of the back and the abdomen. She has no comorbidity and the Caudal anesthesia with GA was discussed with her and she agreed and consent was signed . Blood investigations were done including coagulation profile . First we started with GA with propofol and Remifentanil after turning the patient prone, Caudal anesthesia was given . postoperative protocol for analgesics was as follows: Paracetamol 1 gm intravenous every 8 hours if pain score is 4 or less and 50 mg Pethidine intramuscular if pain score is 5 or more

Operation was done successfully and patient shifted to PACU pain -free with No post-operative side effect of narcotics. Her first request of narcotics was after 18 hours and only Paracetamol Every 8 hours.

Caudal Block prolonged the analgesia postoperative with minimal or no side effects from narcotics

Enhanced recovery after surgery (ERAS) protocols have shown to improve patient outcomes in donor nephrectomies.The Donor Nephrectomy Improvement Programme at our hospital aided formation of ERAS guidelines in 2020. The first 3 phases of the project used to standardise anaesthetic technique have shown great improvements in the patient experience (Figure 1 +2). We aim to see if the improvements from the previous 3 phases have been maintained, and what the results from individual anaesthetists are.

Ethical approval was not required as per the local audit committee. A retrospective search conducted from the Renal Transplant Database identified 109 donor nephrectomy patients from the introduction of the ERAS guidance over a 22-month period. Clinical notes were analysed reviewing: compliance with the guideline; length of stay; mobilisation day and intravenous morphine equivalents 48 hours postoperatively. Individual anaesthetists were only included if they had performed >5 cases. A case was deemed ‘compliant’, if all intraoperative/postoperative guidance was followed precisely.

The percentage of cases the anaesthetist was fully compliant with the guidelines varied from 0-75% (Figure 3). From Figure 3, there is a correlation between high compliance and lower opioid use, a result repeated when analysing maximal pain scores.

The ERAS programme and technique guidelines have hugely reduced variation in pain experience from phase 1 to 4. However, the variety between individual anaesthetists that remains can be explained, in part, by a lower degree of adhering fully to current guidance, with non-compliance associated with worse outcomes. Results have been fed back to the individual anesthetists.

Postoperative pain management remains a critical challenge. Opioids have been commonly used for postoperative pain management in various surgeries. However, their adverse effects, including dependency and addiction, have led researchers to seek alternative pain relief methods, such as multimodal analgesia. Liposomal bupivacaine is a component of multimodal regimens that encapsulates local anesthetic in multivesicular liposomes, potentially providing consistent pain relief for up to 72 hours. This investigation aims to evaluate the effectiveness of liposomal bupivacaine in reducing opioid use and related adverse effects in patients undergoing surgery.

The efficacy of liposomal bupivacaine in postoperative patients remains relatively unexplored. This review examined the literature, focusing on investigations of its use in postoperative patient populations.

The findings yielded mixed results. Some reports found no significant difference in postoperative pain scores within the first few days, while others reported lower pain scores on the day of surgery. Postoperative narcotic consumption assessment revealed no significant difference between the control group and the liposomal bupivacaine-treated group in some cases.

Interpretation of the available data is challenging due to significant variability in study design and comparison groups. Prospective, randomized clinical trials are needed to fully assess liposomal bupivacaine's efficacy in postoperative patients. Clinicians should critically evaluate the existing data before implementing liposomal bupivacaine widely and continue to emphasize opioid-minimizing pain management strategies. In conclusion, liposomal bupivacaine offers a promising alternative for postoperative pain management in elective surgeries. Future research should focus on optimizing its use and assessing its cost-effectiveness to maximize patient outcomes and satisfaction.

Thoracic epidural analgesia (TEA) has traditionally been used for pain management after open liver resection (OLR). Despite its proven analgesic efficacy, TEA may not have the optimal safety profile. Limitations include the risk of epidural hematoma and unplanned delays in postoperative removal of the epidural catheter due to coagulopathy. Intrathecal morphine (ITM) in a multimodal analgesic scheme is an alternative to decrease postoperative pain intensity and opioid requirements. However, there is still no consensus regarding the most appropriate dose that provides effective analgesia while avoiding the risk of side effects. The aim of this work is to assess the analgesic efficacy and the presence of side effects of a low dose of ITM (150 mcg) in patients undergoing OLR. The patients informed consent for publication was obtained.

We retrospectively evaluated 3 patients who underwent OLR and that received 150 mcg of ITM as part of a multimodal analgesic scheme.

Patients were evaluated by an anesthesiologist 24 hours after surgery and reported no pain at rest and slight to no pain at movement, with no need for rescue analgesia. No side effects were documented, namely respiratory depression, nausea, vomiting, urinary retention, or pruritus.

Low dose of ITM could be an effective strategy to include in a multimodal analgesic scheme to control pain after OLT, with a low risk of respiratory depression. It could avoid the placement of an epidural catheter and the risks associated in case of postoperative coagulopathy.

This case report highlights the successful treatment of excessive sweating related to Intrathecal (IT) morphine with atropine.

A 23-year-old male patient, weighing 70 kg and measuring 172 cm, referral to our clinic for segmentectomy. Preoperative vital signs were normal. After obtaining consent from the patient, spinal analgesia was performed 350 mcg of IT morphine. Anesthesia induction was achieved with propofol, rocuronium bromide, and remifentanil. A double-lumen endotracheal tube was placed in the left main bronchus. Forced-air warming was used to prevent hypothermia. Video-assisted thoracoscopic surgery was performed on the left hemithorax, and the mass was excised. Sweating was observed on the patient's head and upper body starting from the second hour of the operation. No other intraoperative complications occurred. Three hours later, extubation was performed with suggamadex. Upon arrival in the recovery room, the body temperature was 33.2°C. The patient continued to experience excessive sweating. 0.5 mg of atropine was administered and miraculously, the sweating stopped within 1-2 minutes. With the normalization of vital signs and body temperature, the patient was transferred to the ward. As the patient remained asymptomatic during follow-ups, he was discharged on the second postoperative day.

Rarely, excessive sweating accompanied by hypothermia can be observed after IT opioid injection. Among the active treatment options, naloxone and lorazepam are included. Atropine is suggested as an option. Acetylcholine is the main pre- and postganglionic neurotransmitter of the sympathetic nervous system that innervates sweat glands, thus the use of anticholinergic medication like atropine significantly reduces or eliminates sweating.

Opioids are widely utilized agents for pain control, both intraoperatively and postoperatively. However, due to the abundance of adverse effects associated with their use such as nausea, vomiting, respiratory depression, ileus, delayed gastric emptying and pruritus, the use of opioid-sparing and opioid-free techniques have gained growing interest as part of a multimodal analgesic approach. In this context and in the era of an ever-increasing opioid epidemic, regional anesthesia and analgesia techniques are an interesting supplementary alternative aiming at minimizing opioid use.

In this report, we present the use of an opioid-free general anesthesia modality in conjunction with a thoracic epidural technique in an elderly patient with comorbidities who underwent pancreatoduodenectomy. The anesthetic technique was based on the Mulier protocol. In specific, 0.1 mcg/kg dexmedetomidine, 0.1 mg/kg ketamine and 1 mg/kg lidocaine were administered as a bolus, followed by a continuous infusion of a mixture of dexmedetomidine 0.1 mcg/kg/h, ketamine 0.1 mg/kg/h and lidocaine 1 mg/kg/h throughout the operation. Before skin incision, an additional bolus of ketamine 0.5 mg/kg was administered, followed by 40 mg/kg of magnesium and 8 mg of dexamethasone. The anesthetic was supplemented by a low thoracic epidural. Intraoperatively and postoperatively, complete avoidance of opioids was achieved.

We demonstrated a paradigm of complete avoidance of systemic intravenous administration of opioids intraoperatively and postoperatively in an elderly patient with comorbidities scheduled for pancreatoduodenectomy.

An opioid-free anesthetic is feasible and can be delivered successfully even in open gastrointestinal surgical procedures, where analgesia has traditionally relied on the use of opioids.

Pain management plays a crucial role in patient care and should be a fundamental priority in therapeutic interventions. This survey aimed to assess the perspectives of caregivers and patients regarding pain management by evaluating professional practices, obstacles to analgesia, and patient satisfaction.

A descriptive cross-sectional study was conducted among healthcare caregivers and patients. Three comparative questionnaires were used to collect data.

A total of 109 professionals (32 doctors and 77 nurses) and 36 patients participated in the study. The majority of nurses (79%) and physicians (85%) reported systematic pain assessment, with 32% and 50% respectively using a standardized tool. Doctors demonstrated regular checking of prescription compliance (68%) and treatment adaptation (89%). Caregivers actively sought possible side effects (90%). Barriers to analgesia were identified by 64% of doctors and 42% of nurses, including challenges related to tailored pain medications, limited time, and insufficient training. Inadequate knowledge and apprehensive attitudes towards opioid side effects were noted as limiting factors. Patient responses revealed that 75% reported being assessed and managed for pain, but 60% believed that their reassessment was inadequate. Only 33% expressed complete satisfaction.

Our findings indicate inadequate pain management practices, highlighting the need of a dedicated pain control committee as an active catalyst and coordinator of pain treatment. This committee aims to integrate pain management as a routine hospital care practice, employing a structured and collaborative approach. The key objectives include increasing awareness, developing educational programs, and providing clinical training.

Effective pain management is a key priority at our institution and is coordinated by the Pain Control Committee (PCC), which is a regulatory and multidisciplinary board established in 2018. In this study, we aimed to evaluate the PCC's activities and impact in improving pain management.

An observational study was conducted by reviewing data from annual reports and patient records.

Since its implementation, the PCC has trained nearly 300 participants (primarily paramedics) , through seminars and workshops. Additionally, 25 documents outlining pain assessment and management, including 2 standard operating procedures, 13 protocols, 2 informative documents, and 8 algorithms, were written, validated, and transmitted across all relevant departments. The clinical training of a pain expert nurse and a physiotherapist failed due to organizational reasons. The most common challenges faced by the PCC included a lack of traceability, time, and willingness of senior practitioners and pain referents to actively adhere to the committee's teamwork actions. The main limiting factors were the lack of therapists with advanced training in acute and/or chronic pain management, such as anesthesiologists and psychologists, as well as financial issues.

Real-world evidence revealed many insufficiencies and challenges in the implementation of the structured plans of pain management committee. Sustained efforts and a never-ending commitment to pain management are necessary to maintain the virtuous circle of continious improvement. The Deming Cycle (Plan-Do-Check-Act) can help improve organizational efficiency in this regard.

Despite of similar postoperative pain control and less adverse effects, thoracic paravertebral block (TPVB) for thoracotomy and video assisted thoracic surgery (VATS) isn’t as widespread as thoracic epidural anesthesia (TEA). To standardize clinical practice in our institution, we conducted a retrospective observational study to compare postoperative pain control after VATS.

We performed a retrospective cohort analysis of patients who were undergoing VATS oncological lung surgery with regional anesthesia (TEA or TPVB) during 2021. Significant pain was considered if a value ≥3 was recorded with the verbal numeric scale (VNS) at 12, 24 and 48 hours (h) after surgery. The need for rescue analgesia at those times was also registered. A Chi Square test was used to compare both groups.

44 patients were included in the study, 22 in each group (continuous TEA vs. single shot TPVB at two thoracic levels). Patients at both groups had similar VNS pain values and need for analgesia rescue at 12, 24 and 48h with no statistically significant differences between them (VNS 12h (p=0.275), 24h (p=0.3834), 48h (p=0.275).

Our findings are in line with recent literature, showing that TEA and TPVB may be equivalent effective regional analgesia techniques in VATS in terms of postoperative pain control. Nevertheless, differences may have not been found due to sample limitation. Adverse effects have not been analyzed due to incomplete data.

Shoulder surgery causes moderate to severe pain .In this case series we have combined low volume C5,C6 root block with postoperative Erector spinae plane block ( ESPB) and studied the analgesic efficacy,involvement of the diaphragm and other complications after Shoulder surgery.

Thirteen patients undergoing shoulder surgery under general anaesthesia were given C5 -C6 root block with 0.375% ropivacaine 6 to 8 ml before incision. Before extubation ultrasound guided ESPB at T2 was given using 15 ml of 0.375% ropivacaine along with intravenous paracetamol and diclofenac.Ultrasound guided diaphragmatic assessment was done preoperatively and after extubation. Each patient was assessed postoperatively at regular intervals upto 24 hours for visual analogue score and requirement of analgesia.

Average visual analogue score (VAS) upto 6 hours was 0, at 12 hours was 0.54, 18 hrs 1.62, 24 hrs 1.92.Rescue analgesics were needed once, in 4 patients (30 %) at 12, 13, 14, 16 and in three patients (23%) at 18 hours.The average duration of analgesia was 18 hours. No diaphragm involvement or other complications were noted .

C5-C6 root block combined with postoperative ESPB for shoulder surgery reduced the requirement for rescue analgesic,lowered the VAS and spared the diaphragm with no adverse event.

Postoperative analgesia after TAH remains a challenge. In our hospital, we commonly use one of two protocols: parenteral analgesia with intravenous DIB or regional analgesia with epidural DIB supplemented with parenteral analgesia. The study compares the analgesia achieved in the first 48 hours and describes complications.

We collected data from January-2022 to March-2023 using The Acute Pain Management Team database, with patient consent. 60 cases of oncological or non-oncological TAH were randomly selected, in a 1:1 proportion (parenteral vs epidural analgesia). The parenteral group received a 2mL/h DIB for 48h with metamizole and tramadol and the epidural group received a 5ml/h DIB for 27h with 0.1% ropivacaine. Both groups received intravenous acetaminophen 1g-qid and ketorolac 30mg-tid; morphine was used as rescue analgesic. Pain scores, rescue medication and complications at 24 and 48h were collected.

There are no demographic differences between both groups (table 1). Surgical diagnosis varied (p=0.001), as well as a tendency towards longer hospitalization in the epidural group (p=0.009). Post-operative visual analogue scores at rest and in movement were comparable in the first 48h, as well as total morphine consumption (p=0.354), nausea and vomiting (p=0.195).

We conclude that intravenous DIB and epidural DIB are comparable in the management of postoperative pain of TAH. Morphine consumption and side effects were comparable, but significant paresthesia was seen in the epidural group. The authors recognize the small sample bias, but highlight the importance of good pain management with a less invasive technique. However, epidural technique should be considered for high-risk cases.

Post-operative pain management in patients undergoing total hip and total knee arthroplasties (THA, TKA) can be challenging. Gabapentinoids, drugs normally used for patients with chronic neuropathic pain, are often used in the perioperative setting as an adjunct therapy to ameliorate patient’s analgesia and decrease opioid consumption. Several metanalysis have been conducted to investigate the effect of gabapentinoids’ preoperative administration, showing negative results in most cases. Conversely, a meta-analysis from Han et al. showed a reduced post-operative opioid consumption in patients treated with pre-operative gabapentin.

We conducted a case-control observational study on 135 patients undergoing a total hip or a total knee arthroplasty. Our primary outcome was to assess if there was any statistically significant difference in pain scores at several timepoints. In our center, the gabapentin was administered as a single, low dose preoperative oral dose.

55 patients received a pre-operative dose of gabapentin. The numerical rating score (NRS) was 2.5 and 1 point lower in the gabapentin group, respectively at 6 hours and 18 hours after the surgery, when compared to the patients that did not receive gabapentin, with a meaningful difference. The other observed timepoints did not show a significant result. The post-operative length of stay (LOS) in the post-anaesthesia unit and the overall LOS were similar in the two groups.

In out analysis, the use of a low dose of preoperative gabapentin was safe and effective in reducing the postoperative pain scores in the first day post-surgery. However, its effect run out 24 hours after the surgery.

Transversus Abdominis Plane block is a technique to provide postoperative analgesia following abdominal surgery. Ultrasound-guidance has greatly improved the accuracy of TAP-block. However, even with ultrasound, it is not always easy to depose the local anaesthetic precisely in the transversus abdominis plane. We studied whether the addition of an injection pressure monitor could improve the accuracy of TAP block.

We performed ultrasound-guided TAP-block at the end of surgery in 30 patients, 18 - 65 years old, ASA score 1-2, who underwent open appendicectomy or inguinal hernia repair, in Erbil Teaching Hospital, Iraq. We administered 20 mL of local anesthetic (bupivacaine 0,25). Standard analgesic protocol consisted of: 1 to 2 mcg/kg fentanyl during induction, 1 g paracetamol and up to 30 mg ketorolac post-op. 100 mg tramadol was used as rescue medication. We assessed the injection pressure by use of the BSmart injection pressure monitoring device, of both intra-muscular and intra-fascial injection sites, in all patients. Postoperative pain was scored according to numerical rating score.

The injection pressure at the intra-fascial site was higher (15-20 psi) than at the intra-muscular site (<15 psi) in all 30 patients (p<0.05). Postoperative pain scores (at recovery, 1h, 3h and 6h postop) are shown in Table1. Briefly, 28 out of 30 patients had no or mild pain, 2 out of 30 patients had moderate pain.

The use of an injection pressure monitoring device could possibly improve the accuracy of ultrasound-guided TAP-block, by confirming a higher injection pressure (15-20 psi) at the intra-fascial site.

Rebound pain after regional anaesthesia (RA) is often an under-recognised yet debilitating condition occurring after resolution of the nerve block. Rebound pain disrupts functional recovery, postoperative discharge and patient satisfaction. This retrospective audit aimed to investigate the incidence and factors associated with rebound pain in patients undergoing surgery.

Data was retrospectively collected from patients who underwent surgery in Khoo Teck Puat Hospital, Singapore, over a period of 1 year, and had received single-shot peripheral nerve block or spinal anaesthesia. Patient demographics, surgery types, Visual Analogue Scale scores, upon resolution of RA, were collated.

A total of 1177 patients were studied. Incidence of severe rebound pain was low, 0.8% at rest and 4.5% on movement. Incidence of moderate rebound pain was 6.4% at rest and 19.1% on movement. Age ≤ 55, Indian ethnicity, surgical type and surgical site were associated with increased rebound pain at rest (p<0.05). Female gender, Indian ethnicity and surgical site were associated with increased rebound pain on movement (p<0.05). Moderate-severe rebound pain at rest and movement were common in tibia surgeries (66%) , shoulder surgeries (53 – 73%) and below-knee amputations (20 – 60%).

Younger patients (< 55 years old), Indian race, and operations such as shoulder, tibia and below-knee amputations have higher rebound pain scores. Understanding the risk factors can help to identify patients who will benefit from measures such as preemptive multimodal analgesia before block recession and continuous RA techniques.

Introduction: Patients on long-term opioid therapy, such as buprenorphine, pose a significant challenge for perioperative pain management. Regional anesthesia has emerged as a preferred method of treatment for these patients.

Case report: A 47-year-old patient with a history of long-term buprenorphine/naloxone (8mg/2mg)/12h therapy was admitted to hospital for total knee arthroplasty. After obtaining informed consent, it was agreed that the surgery would be done entirely under regional anesthesia. On the day of surgery, preemptive analgesia of paracetamol 1g orally was prescribed before the patient was transferred to the anesthesia preparation room. Standard ASA monitoring was established, and the patient was premedicated with 2mg of iv midazolam and 8mg of iv dexamethasone. Ultrasound-guided peripheral nerve blocks were performed using a total volume of 48 ml of both diluted and non-diluted 0.5% levobupivacaine, including iPACK, anterior femoral cutaneous nerve block and modified genicular block with inferolateral genicular nerve exclusion. In addition, a catheter was placed in the adductor canal at midvastus level, followed by spinal anesthesia administered at L4/L5 level. Postoperative analgesia in the ward was provided by bolus catheter doses of 15 ml of 0.2% ropivacaine/8h, iv paracetamol 1g/8h, and iv ketoprofen 100 mg/12h for two consecutive days.

Results: The maximum reported pain intensity on the day of surgery was VAS 2, VAS 3 on the first postoperative day, and VAS 0 on the second day, after which the catheter was removed.

Conclusion: The combination of regional anesthesia techniques and non-opioid medications provided excellent analgesia for patient taking buprenorphine.

Patient controlled epidural analgesia (PCEA) aims to give patients increased autonomy, while tailoring dose to minimize adverse effects. Our Acute Pain Service (APS) developed an institutional protocol for PCEA with ropivacaine 1 mg/mL, optional morphine 20 mcg/mL, bolus 4 mL, lockout 30 min, and infusion 4-8 mL/h. A quality and safety assessment was performed nine months after implementation.

Data collected by the APS was retrospectively reviewed for pain control and local anesthetic consumption at postoperative days one and two, adverse events, and patient satisfaction. Electronic health records were also screened for adverse events. The audit was considered exempt from Ethics Committee approval.

PCEA was used in 81 patients following upper and lower digestive, thoracic, gynecologic, urologic, and retroperitoneal surgery. Epidural morphine was used in 83%. Median numeric rating scale for static pain on day one was 0 (IQR 2), and for dynamic pain 3 (IQR 2). Median static pain on day two was 0 (IQR 1), and dynamic pain 3 (IQR 2). Mean volume infused was 107 mL (SD 55 ml) at day one and 117 mL (SD 58 ml) at day two. Hypotension (23%) and nausea and vomiting (19%) were the commonest adverse events. Off-hours anesthesiologist intervention was required in 20% of patients. Of 69 patients inquired, 96% were satisfied with the analgesia.

An institutional protocol facilitates adequate continuous improvement. An organized APS and stakeholders’ education are crucial for implementation. Pain control and patient satisfaction were good. Future adjustments to the protocol might decrease adverse events.

Pectoral nerve (PECS) blocks have demonstrated promising results in randomized clinical trials, including reduced postoperative pain scores and opioid consumption following breast surgery.This retrospective study aimed to present the experience with PECS blocks and evaluate their effects on the quality of recovery(QoR) and postoperative pain.

We retrospectively evaluated the records of patients who underwent modified radical mastectomy.A total of 43 patients were included in the study.In addition to routine intraoperative analgesics, PECS blocks with 30 mL of 0.25%bupivacaine were administered preoperatively in 14 patients(Group Pre-op) and postoperatively in 16 patients(Group Post-op).Thirteen patients received no block andserved as the control(Group Control).We compared demographic characteristics, mobilization time, first analgesic time, and quality of recovery score(QoR-40) at the 24th postoperative hour.The numeric rating scale(NRS) at rest and during movement(0-10;0,representing no pain;10,the worst imaginable pain), were also evaluated at various time points up to the 24th hour postoperatively.

There were no significant differences observed in demographic characteristics, the mobilization time, first analgesic time, and QoR-40 score at the 24th postoperative hour among the groups.Although the NRS scores at the 2nd,6th,18th,and 24th hour were lower in Group Pre-op and Group Post-op compared to Group Control, with more pronounced differences observed in Group Post-op, no statistical significance was found among the groups.

The administration of preoperative and postoperative pectoral nerve blocks did not demonstrate superiority over the control group in improving the quality of recovery.However, due to the limited number of cases and the retrospective nature of the study, further support from prospective studies is warranted.

The widespread use of ultrasonography in regional anesthesia in recent years; resulted in identifıcation of new blocks such as serratus plane block (SPB). SPB is a regional analgesic technique that blocks T2-T9 which has an excellent role in postoperative pain management for cardiothoracic surgeries. We performed SPB for postoperative analgesia in 5 patients undergoing minimally invasive heart valve surgery (MIHVS).

After obtaining informed consents, SPB block was performed after induction of general anesthesia and before the surgical incision, using 1,5mg/kg 0.25% bupivacaine. Pain was measured using a visual analogue score (VAS) (0, no pain; 10, worst pain imaginable) in recovery and at 6th, 12th, 18th, and 24th hours. VAS was less than 3 for the 24th hour and patients had no need for additional analgesics for a post-block period of 12 hours.

SPB provides prolonged postoperative analgesia in patients undergoing MIHVS. Further randomized controlled trials are needed to enhance the efficacy of the SPB.

Thoracic pain is thought to be transmitted via nerves originating from T2 to T9. Blockade of unilateral intercostal nerves can provide sufficient analgesia after MIHVS. Combination of opioids, non-steroidal antiinflammatory agents and regional methods; with different mechanisms of action in postoperative pain management is considered to be more effective for post­ operative analgesia and minimizes side effects as well as reduces incidence of chronic pain.

Perioperative pain treatment affects well-being and recovery after surgery.1-3 Some studies show that women tend to report higher pain and opioid-related adverse-effects.4-5 We aimed to assess sex-related severity of post-operative pain and opioid-related adverse-effects.

Patients after general surgery were asked to fulfill patient-reported outcomes (PRO)6-7 on first post-operative day between 01/2018-05/2019 in our center. We report findings for the abdominal surgery sub-group. Composite pain score (CPS) was created for PROs addressing pain intensity and interference with activity/mood. Secondary outcomes included analgesic administration and composite opioid adverse-effects score (CAES). Logistic regression was used to identify variables associated with CPS≥5.5 and CAES≥4. The study had IRB approval.

205 patients underwent open abdominal surgery, 410 had laparoscopic/combined surgery. There was no difference in analgesics administration between sexes. In the complete cohort a larger proportion of females reported CPS≥5.5 (OR 2.3,p<0.0001). However, epidural anesthesia in open abdominal surgery reduced pain in all patients and eliminated sex differences. BMI<35, Muslim religion and intraoperative ketorolac were associated with reduced postoperative pain (in trend, p=0.06). CAES≥4 was associated with female sex (OR 2.6,p<0.0001), and tramadol administration (OR 3.5,p=0.036).

Females reported higher postoperative pain and opioid-related adverse-effects after abdominal surgery. Epidural reduced pain intensity and eliminated sex differences. We attribute the higher opioid-related adverse-effects in females to a higher exposure to tramadol adjusted to weight. Our results support using epidural analgesia during and after open abdominal surgery in men but especially in women, as well as considering lower doses of tramadol in women as part of multimodal analgesia.

THA is associated with severe postoperative pain. SIFIB is a reliable analgesic option as a part of multimodal analgesia, reducing pain, opioid consumption and its related adverse effects. Adequate pain control is important for early ambulation and patient satisfaction. However, SIFIB may potentially lead to decreased motor strength of quadriceps, delaying physical rehabilitation and discharge.

We report a case of a middle-aged male submitted to right THA using SPAIRE technique for treatment of coxarthrosis.

A 43-year-old male (ASA I, BMI 21) was scheduled for elective uncemented THA. A spinal single-shot block through the L3/L4 intervertebral space (paravertebral approach), in left lateral decubitus position, was achieved after 3 attempts, with a 27G Quincke needle and injection of 9mg of levobupivacaine and 2ug of sufentanyl. Intraoperative course lasted 90 minutes and was uneventful. Acetaminophen (1g), ketorolac (30mg) and dexamethasone (8mg) were administered. An ultrasound-guided SIFIB was performed post-operatively, using a 50mm echogenic needle and 20mL of 2mg/dL of ropivacaine, without complications. After 48h, the patient had right quadriceps motor weakness (2-3/5) and hypoesthesia of L2-L4 dermatomes. A spine and hip CT scan were negative. Dexamethasone, gabapentin, cyanocobalamin, pyridoxine and thiamine were prescribed. After 72h, physical examination was normal (muscular strength 4-4.5/5 with no sensory changes). One month later no sequelae were observed.

SIFIB is an easy to perform and safe block that provides analgesia for hip joint and femur procedures, facilitating postoperative rehabilitation. Sensory and motor block can delay mobilization, but with no nerve damage, sequelae are unlikely.

The transversus abdominis plane (TAP) block is a regional technique for anterolateral abdominal wall analgesia. It is widely used for postsurgical acute pain management, in the context of a multimodal opioid-sparing analgesia. The cornerstone of major abdominal surgery pain management is continuous epidural analgesia. However, especially in the ICU environment, the insertion of an epidural catheter, in addition to being affected by the coagulative arrangement, could be contraindicated by antiaggregation or anticoagulation therapy. It also required advanced technical skills. Moreover, TAP block presented fewer contraindication and it is a rather simple procedure with a shallow learning curve ant it provides long-lasting analgesia.

Patient, 67 years-old, admitted to ICU for post-surgical management after a duodenocephalopancreatectomy for cholangiocarcinoma. In 12th day he developed an acute abdominal pain, prevalent in the upper quadrants, radiating to the back, with a progressive anemization. The clinical pain manifestation, described by patient, seemed suggestive for acute post-surgical pancreatitis. We decided to make a TAP block for pain relief and to discriminate between visceral or somatic pain. Within few minutes, the patient was free of pain. So, in the suspicion of hemorrhagic complication, as the pain trigger, we performed a FAST-US which revealed free fluid around liver and in the Douglas cavity. The patient was subjected to a CT confirming the US finding and he underwent an abdominal surgical procedure.

We described a case report in which TAP block was successfully used in the differential diagnosis of an acute abdomen in critical care setting.

Long-acting spinal anaesthesia with high-dose intrathecal opiates has become the standard for enhanced recovery programmes for colorectal cancer surgery. Our department previously demonstrated that short-acting spinal anaesthesia using prilocaine combined with fascial plane blocks and catheters was effective, with reduced haemodynamic instability and earlier patient mobilisation. We now describe a case series utilising a novel adaptation to this approach, with liposomal bupivacaine (Exparel) fascial plane infiltration.

Fifteen patients undergoing major laparoscopic colorectal surgery were included between October 2022 and May 2023. All patients received 3.0ml of intrathecal 2% hyperbaric prilocaine combined with 100-200mcg of preservative-free morphine. In addition patients received ultrasound-guided lateral transversus abdominis plane (TAP) and rectus sheath fascial plane infiltration with a local anaesthetic admixture of 20mls of 13.3mg/ml Exparel combined with 40mls of 0.25% levobupivacaine and 20ml normal saline. All patients also received 1g paracetamol, and either parecoxib 40mg or ibuprofen 400mg intravenously (if not otherwise contraindicated).

Intra-operatively patients behaved with haemodynamic stability, with no patients requiring vasopressor support post-operatively. In the recovery area, all patients were able to sit up and ambulate with an average post-operative pain score of 0.25. Mean length of hospital stay was was 10.3 days (7.5 after removing one major outlier) and over half of patients did not require HDU monitoring post-operatively at all.

The combined use of Exparel fascial plane blocks with short-acting spinal reduces the opiate requirement in the peri-operative management of laparoscopic colorectal surgery. Excellent long duration analgesia and haemodynamic stability is provided with a minimal side effect profile.

Peripheral nerve blocks rather than systemic analgesia are usually used in older patients with fracture neck femur. In this study, we compared fascia iliaca vs PENG with LFCN block for fracture neck of femur surgery.

Geriatric group of patients of age 70 years or over, ASA 2 & 3 with body weight 50 to 90 Kg were included in our study. Out of 40 patients, 20 were taken alternatively for fascia iliaca (Gr-F) or in PENG with LFCN (Gr-P) group. Drugs mixture for the nerve blocks contained equal volume of 2% Lidocaine in adrenalin and 0.5% bupivacaine (plain) with 10 mg dexamethasone. Ultrasound-guided peripheral nerve block was performed with 40ml for FI block in Gr-F and 30ml ml and 10 ml respectively in Gr-P for PENG and LFCN blocks. VRS was assessed 30 minutes following the nerve block procedure. All patients received CSE with 10 mg Bupivacaine heavy for spinal anesthesia and Inj. dexmedetomidine infusion at 0.5 mic/kg/hr for sedation as our routine anesthetic technique in the intraoperative period. Pain, hemodynamics, complications, timing of initiation of epidural infusion were studied.

Students T test was applied for the analysis. During positioning VRS score at 30min was Gr-P 1.15 (± 0.344), in Gr-F it was 2.2 (± 0.589) (p<0.0256). Per-operative hemodynamic responses were not significantly different (P<0.08). Duration of analgesia in Gr-P was 16.96 (±1.86) hours and Gr-F 13.69 (± 1.04) hours with P value <0.293.

PENG with LFCN block revealed better analgesic quality during positioning for CSE performance in our study.

In our institution, a common practice for providing motor-sparing analgesia after total knee replacement (TKR) is by combining the distal IPACK with adductor canal block. These blocks are typically administered preoperatively after spinal anesthesia to enable pain-free early exercise or deambulation as the neuraxial block wears off. However, in this case report, we describe an inadvertent sciatic block following proximal IPACK block.

Informed consent for publication was obtained. A 69-year-old woman scheduled for TKR, was admitted to the preoperative room with delay. Since the patient arrived late, we decided to proceed with spinal anesthesia and surgery, postponing the analgesic blocks to the recovery area. In order to avoid dressing manipulation and to maintain distance from the prosthesis, we performed the IPACK block postoperatively using the proximal technique, approximately two fingers above the patella in supine position. We injected 20 ml of 0.5% ropivacaine with dexamethasone 4 mg between the popliteal vessels and the femur.

The first evaluation was postponed to the following morning since it was late afternoon when the block was performed. The patient presented with complete sensory and motor block below the knee, which resolved completely about 18 hours after the block.

Proximal approach to IPACK may increase the risk of local anesthetic spreading toward the sciatic nerve and subsequent motor block. Therefore, we recommend performing this block with nerve stimulator or to chose alternative analgesic techniques for the posterior capsule of the knee, unless a clear US real-time visualization of the nerve structures during injection is possible.

Currently, pain is mainly assessed through observation of vital parameters and based on the patient's self-report, turning the objective evaluation of pain barely impossible. Moreover, the inherent subjectivity of these pain evaluation procedures may result in potentially harmful consequences due to over or under-dosage of analgesics. Thus, pain assessment needs to be accurate to allow efficient pain management and effective support of healthcare strategies, leading to personalized medicine. In the experience of pain, Heart Rate (HR) provides useful and critical information.

Twenty volunteer adults, with 60 ± 21 y.o., undergoing elective surgery at Tondela-Viseu Hospital Centre (Portugal), participate in this study. During the recovery, ECG was continuously recorded, and self-reported pain was assessed. ECGs were processed to compute HR, and several metrics, which serve as pain predictors, were calculated. These metrics were then used to build a k-nearest neighbors (kNN) machine learning model for postoperative pain (POP) prediction (“pain” vs. “no-pain” classification).

The k-nearest neighbors (kNN) achieved an F1-score of 92%, an accuracy of 86%, and a sensitivity of 100%, indicating 100% recognition rate for POP. These results sustain that HR information can be used for POP prediction.

The kNN was trained and evaluated on recorded ECG data, thus further research will focus on the proposal of models to predict POP along with the monitorization of ECG, providing a useful tool for the online support of therapeutic approaches, namely through a better dosage of analgesics, either by different pharmacological interventions or by cognitive-behavioral therapies.

Although several studies have demonstrated efficacy of low-dose intravenous ketamine infusions in the perioperative period, there is little to no research investigating the use of high dose ketamine boluses for phantom limb during the acute postoperative period. This case demonstrates the success use of high dose ketamine to alleviate acute, postoperative, phantom limb pain following electrode implantation and total shoulder with proximal humeral replacement for transdermal osseointegration, after failing all other traditional postoperative phantom limb pain regimens.

Direct patient care as well as retrospective chart review.

The patient was extubated in the OR and admitted to the ICU postoperativley, for pain control and started on the following pain regimen by the acute pain service: Ketamine gtt at 0.3mg/kg/hr, Subutex 8mg TID, Robaxin 500mg QID, Acetaminophen 1g TID, Lyrica 75mg TID, and IV Dilaudid 0.5 mg q3H PRN for breakthrough. Over the course of the next eight days patient also received daily IV ketamine boluses by a Physician, in 20mg increments, every 10 minutes for up to 5 doses, titrated to effect. The patient received between 60-100 mg of ketamine total during each “bolus session” which occurred twice a day.

This case contributes to the experimental evidence that high dose ketamine can be used safely to achieve analgesia for refractory, phantom limb pain during the acute, postoperative period. High dose ketamine can be incredibly effective in achieving analgesia in refractory, acute, postoperative phantom limb pain.

There has been dramatic rise in polysubstance abuse including utilization of synthetic compounds. A new combined agent known colloquially as “Fetty Tranq” is an emerging threat. Xylazine, a non-opioid veterinary tranquilizer with direct alpha-2 adrenergic receptor agonism, is being combined with street fentanyl to extend effects and enhance euphoria. Through alpha-adrenergic effects, xylazine produces local vasoconstriction leading to characteristic and progressive wound presentation. Epidemiologic studies demonstrate geographical predominance of this toxic combination in the Northeastern United States, particularly in the city of Philadelphia. The latest health update released by the Philadelphia Department of Public Health in December of 2022 reported detection of xylazine in 90% of street opioid samples.

41-year-old male with several year history of intravenous drug use presented with several islands of necrotic wounds on bilateral lower extremities. Addiction medicine consulted for withdrawal and pain management in setting of active substance use. Patient taken to OR by plastic surgery for excisional debridement of wounds. Right popliteal-sciatic and left adductor canal catheters placed for postoperative pain management by RAAPM service.

Important to recognize, identify and transfer to appropriate level and range of care. This is not a “Narcan-resistant opioid”, but rather a combination of two chemicals with physical and psychological consequences.

After one-month follow-up post grafting to bilateral lower extremities, patient continues local wound care with non-adherent dressings and minimal pain. Purpose of this case report is to exemplify team-based approach and global view of treatment for patient in need of withdrawal treatment, surgical wound care and multimodal analgesia.

Chronic pain presents a significant healthcare burden and can become quite debilitating. The current standards of care for chronic pain include lifestyle management, procedures, and analgesics for acute exacerbations. However, using analgesic approaches has led to significant adverse effects and healthcare burdens. This review aims to investigate the current literature regarding emerging pharmacological approaches to chronic pain.

This investigation eliminated non-pharmacologic therapies and established chronic pain regimens, focusing on three primary drug classes: cannabis, psychedelics, and dissociative hypnotics. Emphasis was placed on ketamine (hypnotic) and psilocybin (psychedelic), with other drugs also considered. Cannabis was treated as a unique drug class due to its distinct mechanism of action and abundant literature.

The review revealed promise in all three drug classes, with marijuana being the most researched yet needing further study on adverse effects. Ketamine showed potential but had abuse concerns; other hypnotics require more evidence of efficacy. Finally, psychedelics, the least understood treatment for chronic pain, demonstrated promise in small studies but need further research on dose-dependent adverse effects, mainly acute psychosis.

Despite limited literature and class-specific concerns, emerging pharmacological pain management approaches can improve patients' quality of life. Issues include abuse potential, acute adverse effects, and legality. Significant progress is needed before these drug classes become standard in chronic pain treatment, but they can potentially reduce the overuse of highly addictive analgesics.

Short-lasting unilateral neuralgiform with conjunctival injection and tearing (SUNCT) is a rare cause of facial pain. It has been associated with vascular abnormalities, intracranial masses and trauma but can occur de novo. We share a case of SUNCT which presented after surgery for retinal detachment.

The patient was followed up weekly over telephone consultation. A pain and symptom diary was kept until resolution.

A 64 year old man underwent retinal surgery for retinal detachment under sub-tenons block. His past medical history included migraine with aura and ocular migraine. On the evening of day 0 the attacks began to occur. They were described as lasting 45-60 seconds total with a maximum severity on the numerical rating scale (NRS) of 9. The pain built up in a crescendo during the attack and the pain was described as stabbing and spasmodic in the orbital region. There was associated autonomic features which included conjunctival injection, tearing, rhinorrhoea, forehead sweating and ptosis. Neuropathic features included hypersensitivity over the ipsilateral forehead. During the cluster of attacks, another could be initiated through palpation over the orbital and temporal region. There were 50-100 attacks daily which clustered over 3-4 hour periods typically in the evening. He was reviewed by the eye clinic on day 1 who advised cyclopentolate and ibuprofen to no effect. The attacks resolved by day 16.

SUNCT can be initiated by peripheral causes as suggested here and in the literature. Therefore it may be an underreported problem after ophthalmic and craniofacial surgery.

There is published discrepancy in peri-operative outcomes between pre-operative users of strong opioids, and non-users. However, there is a paucity of research assessing the effect of optimising pain management pre-operatively, in patients undergoing bariatric surgery. This study assessed if a novel pre-operative referral pathway for high-risk complex chronic pain patients using strong opioids improves outcomes following weight-reduction surgery.

Patients with chronic pain and strong opioid use awaiting weight-loss surgery were identified by a Bariatric Specialist Nurse, referred to the Plymouth Pain Management Service, and were reviewed by a Consultant in Pain Medicine.

Three patients achieved a successful reduction in use of strong opioids; both at hospital discharge and 24-hour post-operative use in these patients. There was no difference in length of hospital in-patient stay between the high-risk chronic pain patient group and the standard patient cohort. A patient feedback questionnaire suggested improved education and understanding of what chronic pain is, a greater awareness of the side effects of opioids, and a positive impact on mental health.

Currently only a select few high-risk chronic pain patients have completed the pain pre-operative optimisation pathway. This approach improves patients’ knowledge and understanding of pain management and reduces their chronic use of strong opioids. Further work is needed with increased patient numbers to provide greater insights into how this process could be optimised to provide a better service to patients undergoing weight-loss surgery who suffer with significant chronic pain.

Different descriptions of long COVID have already been proposed, and the most common description includes symptoms lasting for over three months after the first symptom onset. One of the most frequent symptoms identified, besides fatigue and dyspnoea, is a new daily persistent headache. We describe a case of persistent headache associated with COVID-19, which had a poor response to pharmacological treatment. The patient scored a pain of 8 points in Visual Analog Scale (VAS). It was a widespread—affecting frontal, temporal, and occipital area—pulsating quality headache that worsened with mild physical activity.

Since Botulinum toxin type A has been used to treat chronic migraine for over a decade, we decided to try this therapeutic option after proving that the response to local anesthetics was positive. She responded satisfactorily to bilateral greater occipital nerve block and infiltration of the frontal and temporal muscles with local anesthetic and corticosteroids, with an improvement during approximately 48 hours. Two weeks later, we administered by ultrasound guidance 20 IU of botulinum toxin near the greater occipital nerve, and performed a mapping with botulinum toxin by administering it at different points: both trapezius, splenius, frontal muscles, bilateral orbicularis and bilateral temporal and parietal muscles

After seven days, the patient reported improvement of the symptoms (VAS 3) that were still present one month later.

In conclusion, we propose that botulinum toxin can be a therapeutic option for persistent headaches associated with COVID-19. However, future research studies are required to clarify this possibility.

Caudal epidural blockade (CEB) is a technique also used in chronic pain management. Although fluoroscopy is the gold standard technique, ultrasound gained popularity due to its high success rates, accessibility and lower radiation exposure.

53-year-old man with low back pain radiating to his right leg for six months with paresthesias, difficulty in gait and decreased sleep quality. Lumbar MRI revealed disc protrusions at levels L4-L5, L5-S1 and electromyography showed signs of acute on chronic root distress of the right L5 nerve. One month of physiotherapy and oral analgesia showed no improvement and the patient was waiting for a neurosurgery consultation. We proposed a CEB which the patient consented to.

CEB was performed with the patient in prone and standard ASA monitoring. The sacral hiatus was identified using a linear probe in transverse and longitudinal planes. An ultrasound-guided longitudinal in-plane approach was performed using a 21G needle. After puncturing the sacrococcygeal ligament a solution of 2mL 2% lidocaine, 6mg betamethasone and 8mL saline was administered. Unidirectional flow was confirmed using color Doppler mode. No complications were reported. One month later, the patient returned reporting marked pain relief, normalized gait pattern, and reduced frequency of physiotherapy. He had the neurosurgery consultation, but surgery was delayed due to lack of clinical criteria. After four months the patient remained pain-free.

-Ultrasound demonstrates high success rates in CEB. -Ultrasound allows for lower radiation exposure with more accessible equipment. -CEB is effective in treating refractory low back pain and can delay or avoid more invasive procedures.

Central neuropathic pain syndrome is a neurological complication associated with central nervous system damage. Although the pathophysiology of central neuropathic pain has yet to be elucidated, dysfunction of spinal-thalamic-cortical pathway is critical for the development of central neuropathic pain. We present a case of refractory central neuropathic pain resulting from tumor resection of anterior cingulate gyrus that resolved after frontal cerebral hemorrhage.

We assessed this gentleman’s pain by assessing his Visual Analogue Scale (VAS) and reviewing previous management strategies, current medication and impact of the condition on his life. Brain and spine MRI were performed to find the cause of the pain.

A 62-year-old man presented with central neuropathic pain in both upper and lower extremities resulting from resection of anterior cingulate gyrus glioma. Pain was 8/10 on the VAS with significant impact on the patient’s psychological well-being. Despite epidural blocks, medications, and cervical/lumbar spinal cord stimulator over a 10-year period, only 30% of the pain was relieved. However, after the surgery for left superior frontal gyrus hemorrhage caused by a slip-down injury, his symptoms were completely resolved.

In this case, the altered neural firing following tumor resection of anterior cingulate cortex may lead to central sensitization and pathological pain perception. Possible mechanisms of pain relief may involve an increase in inhibitory synapses projecting from frontal cortex to spinal-thalamic-cortical pathway by superior frontal gyrus hemorrhage. This suggests that superior frontal gyrus is an important region in the central pain processing pathway and provides new insight into central pain treatment.

Cervical Facet Syndrome (CFS) is a frequent cause of neck pain. Invasive measures include radiofrequency and cryoablation, however, there is scarce literature about cryoablation in CFS situations. We present a case of a patient with CFS, who underwent cryoablation of the medial branches of the right posterior roots of C4-C7.

A male patient, 71 years, with history of hypertension, reported neck pain for 4 years, more intense on the right side, although radiating to the left upper limb (peak 8). A TC scan revealed “reduction of the left conjugation channel, possible left C6 commitment”. On clinical exam, he had pain on palpation of the cervical spinal apophyses, all cervical spine arch movements were painful, and the spurling test was negative.

After a positive diagnostic blockade of the medial branches of the right C4-C7 posterior roots, the patient had a pain recurrence after 1 week (peak 5). For this reason, we opted for re-intervention, performing ultrasound-guided, with neurostimulation, cryoablation of the same nerves, uneventfully, pain 0 at the end of the procedure.

Cryoablation consists of the application of cold temperatures causing nerve damage by freezing. It has advantages over radiofrequency, it allows regeneration of nerve fibers, not leading to formation of neuromas and it can be repeated several times. A previous positive diagnostic blockade and the use of ultrasound, with neurostimulation, guaranteed the site to be “cryoablated” with precision and safety. This success story is promising and encouraging, but more studies are needed to confirm the effectiveness of the technique.

Cryoneurolysis is an ultrasound-guided analgesic technique that uses extremely cold temperatures to induce a partial nerve degeneration for stopping the painful signals. There are cases in literature showing a good pain control using cryoneurolisis after rib fractures or other chest wall trauma. Our aim is to evaluate its efficacy on Post-Mastectomy Pain Syndrome (PMPS)

A 59-year-old patient underwent total right mastectomy in 2021. After the surgery she developed thoracic pain from T4 to T7, treated with different drugs with no results. She came to our attention in 2023 and we opted for ultrasound-guided intercostal blocks. We injected 5 ml for each painful dermatome of a mixture: ropivacaine 0.5% and methylprednisolone 40 mg (total: 20 ml). Obtained a good analgesia, we arranged the cryoneurolisis of the involved intercostal nerves: two cycles of 2 minutes of cooling to a temperature of -70°C (using nitrous oxide) with 30 seconds of thawing between cycles were performed. We evaluated our patient at the first visit and 1, 4, 12 weeks after the procedure using pain detect and SF 36 questionnaires.

Patient reported a sudden improvement in pain intensity, Pain Detect dropped from 29 to 4 out of 35 already in the first week reaching the value of 2 in the subsequent controls at 4 and 12 weeks. SF-36 revealed a recovery in physical and social functioning, respectively from 35% to 80% and from 12.5% to 62.5% with a reduction of pain of 77.5%.

Ultrasound-guided percutaneous cryoneurolysis of intercostal nerves is an effective treatment for PMPS.

Bertolotti’s syndrome is characterized by chronic lower back pain caused by transitional lumbosacral vertebrae with a reported incidence of 4-36%. Initial management are usually conservative including physical therapy and medical management. Should conservative management fails, surgical treatments is the mainstay management. Intervention such as radiofrequency (RF) ablation may have a role but is scantly reported

A 44-year-old female with a 25-year history of intermittent lower back pain, which progressively worsens over the last 5 years, was referred to the pain clinic. CT scan confirmed the diagnosis of Bertolotti syndrome with partial sacralization of left L5 transverse process. A diagnostic block was performed and complete pain relief lasted for a few hours. Subsequently a radiofrequency ablation of left iliolumbar ligament was performed but pain relief only lasted for a week. A cryoablation was performed and she reported initial flare up pain for a few weeks and significant improvement for 4 months before gradually returning to baseline levels. A second cryoablation with a different approach, with tip being directed over and below iliolumbar ligament and the junction between the ligament and the ilium.

The patient reported almost instant complete pain relief post-procedure, and did not experience post procedure flareup. The last follow up was 8 weeks post-procedure and she still remains pain-free

There has not been any reported use of cryoablation for the management of symptomatic Bertolotti’s syndrome and we suggest that cryoablation is an effective option in cases not responding to RF ablation. Further investigation of this technique is warranted.

Implantable intrathecal pain pump is a well established chronic pain management method that has been used successfully for the treatment of benign chronic intractable pain of various etiologies. The regulation of the pumps requires repeating monitoring and refill at specific intervals and occasionally reevaluation and modification of the daily dose that the pump administers. The aim of this study was to evaluate the effect of the Covid-19 pandemic to the treatment of these patients.

A retrospective analysis of the data collected from the outpatient departments concerning management and regulation of patients with implanted intrathecal pump for benign pain management. The data of 35 patients were collected regarding the scheduled refills, ability to access medical services, availability of intrathecal drugs and requests to alter dosage with or without COVID infection.

There was no significant alteration to the routine of these patients regarding the scheduled refills and availability of drugs, except one specific type, although these actions were performed under the regulation of each hospital in special designated areas and with full precaution. As far as the effect of infection itself, although many patients experienced some musculoskeletal deterioration, almost all were treated with brief oral pain medication and none received or requested an increase in intrathecal drugs.

From our analysis it seems that the patients with implanted intrathecal pain pumps with having the main drug an opioid were not affected in terms of medical services and pump performance from the Covid-19 pandemic.

DISH syndrome, also known as diffuse idiopathic skeletal hyperostosis, is a musculoskeletal disorder that primarily affects the spine. It is characterized by the abnormal calcification (ossification) of ligaments and tendons where they attach to the bones. This excessive bone growth can lead to the formation of bony outgrowths called osteophytes or bone spurs.Skeletal hyperostosis is rare in young patient.

We present a case of a 48 year old female patient with chronic pain at the right side of her back for 13 years. The pain (NRS 8-10), affecting her daily life, was constant and extends from the level of T8 until T12 vertebrae. She has consulted many doctors of various specialties and tried numerous pharmacological treatments, with no results. The cause of pain was unknown until a year ago when she was diagnosed with Forestier syndrome. The patient came to our clinic totally disappointed and in unbearable pain. Hence she had tried all available pharmacological treatments, with no results. She was reluctant to receive any drugs.

We decided to preform diagnostic blocks of the medial brunch using C-arm guidance. As the blocks were successful we proceeded to radiofrequency ablation of the medial brunch in the same levels (80 Co for 3 min). The patient reports improvement (NRS 3) and is very satisfied.

Radiofrequency ablation treatment is a minimally invasive procedure that can be used to manage pain associated with various spinal conditions, including DISH syndrome. In young patients with DISH syndrome,RFA has been found to be a promising treatment.

Chronic pain represents a significant burden for patients, healthcare systems and society, given its impact on quality of life. Erector spinae plane block (ESPB) was rapidly adapted in clinical practice and numerous cases have been published presenting its effectiveness not only in acute but also in chronic pain.

We present the case of a 39 year old patient with ovarian cancer who developed neuropathic thoracic pain after cytoreduction. She reported constant burning and stabbing neuropathic pain of 10/10 severity on the NRS pain scale, radiating from her spine into the anterior chest wall, mainly at T6 and extending several dermatomes inferiorly. She suffered from significant sleep disturbances and impairment of quality of life. Physical examination revealed allodynia and hyperesthesia over the affected dermatomes with a primary trigger point over the T6 dermatome, 3 to 4 cm lateral to the neuraxial midline. Pain management up to that point had included Pregabalin 300 mg, Tramadol 150mg, Paracetamol 3gr and Duloxetine 60mg daily at the time of consultation, with no improvement.

We performed a ESPB and we injected 0,2% Ropivacaine 20 ml. Within 20 minutes of the block, the patient had obtained complete relief of pain, with an NRS of 0/10 which lasted until now.

The erector spinae block has gained attention as a potential option for chronic pain management, particularly for conditions involving the thoracic or lumbar spine. ESPB has shown promise in providing long-term pain relief in some cases of chronic neuropathic pain.

Dorsal Root Ganglion (DRG) neurons play a vital role in transmitting pain signals to the central nervous system, acting as a filter for afferent signals to the dorsal horn. Dorsal root ganglion stimulation (DRG-S) is a specialized neuromodulation therapy that targets the dorsal root ganglion, offering analgesic benefits for various chronic pain conditions. In recent years, DRG-S has gained popularity as a treatment option for lower extremity neuropathic pain syndromes.

Case Report: This case study involves a 30-year-old male with a history of neuropathic symptoms who experienced moderate to severe pain following low-grade myxofibrosarcoma resection in his left thigh at the age of 13. Despite undergoing several interventional procedures such as peripheral nerve blocks, spinal cord stimulation (SCS), and peripheral nerve stimulation implants, he achieved unsatisfactory results. Consequently, the patient was scheduled for a ganglion root stimulation implant.

DRG-S enables precise targeting of nerve fibers that innervate specific painful regions without indiscriminately activating uninvolved dermatomes. With a thin layer of cerebrospinal fluid surrounding it, the DRG allows for the achievement of stimulation with lower electrical currents and is less affected by positional changes. The mechanism of analgesia through DRG-S involves reversing the central pathophysiological changes within the DRG neurons that perpetuate and amplify neuropathic pain.

Chronic neuropathic pain is a prevalent condition that significantly impacts quality of life. When other neuromodulatory therapies have failed, DRG-S can offer potential advantages for managing lower extremity neuropathic pain syndromes. References: Adv Ther (2022) 39:4440–4473

The impact of four distinct blocks, namely erector spine plane block , stellate ganglion block, sphenopalatine ganglion block and greater occipital nerve block, on headache relief as a symptomatic manifestation has been observed. Existing literature has documented a reduction in the intensity, duration, and frequency of pain, along with enhanced patient satisfaction, in primary headaches. As a result, the possibility of a shared mechanism of action warrants investigation

A comprehensive search of the PubMed electronic database was conducted to identify relevant case reports, retrospective studies and case series encompassing the four blocks and diverse headache conditions. The utilized keywords included sphenopalatine ganglion block, greater occipital nerve block, erector spinae plane block, stellate ganglion block, post-dural puncture headache, tension headache, migraine, and cluster headache

The findings indicate that all four blocks have demonstrated effective alleviation of headache symptoms in a majority of primary and secondary headache cases.

Proposed mechanisms encompass interactions with the trigemino-cervical complex, modulation of cerebral circulation and autonomic outflow. Further exploration of the common pathophysiological mechanisms underlying headaches and the identification of suitable therapeutic targets should be pursued

Congenital hip dislocation (CHD) is caused by abnormal formation of the hip joint during early stages of fetal development. Patients with this disorder may have recurrent hip surgeries and may need physical therapy in the following years. The aim of this case report is to raise awareness among doctors, that hip denervation can be used in pain management for the rehabilitation of patients with congenital hip dislocation.

After repeated hip surgeries, limitation of hip joint mobility developed in a 27-year-old female patient with congenital hip dislocation(Figure 1). Due to her pain, she could not receive restricted treatment and could not continue physical therapy. Repetitive Pericapsular nerve group (PENG) blocks (bupivacaine %0.125 + methylprednisolone 40mg mixture) were applied to the patient under USG guidance, and the pain was relieved for a limited time. A perminent pain relief theraphy was sought. Sensory branches of the obturator and femoral nerve pulsed radiofrequency (PRF) (for 6 minutes at 42 degrees) which is called hip denervation, were applied to the patient for long-term pain management under fluoroscopy guidance.

After the intervention, the patient's pain decreased and she was able to continue physical therapy and exercise. At the 6th month follow-up, the patient's pain was under control. No procedural adverse event was noted.

The use of this hip denervation technique for hip pain control is evolving. In our experience, percutaneous radiofrequency lesioning of the sensory branches of the nerves innervating the hip joint can be an option for patients with intractable hip joint pain.

Inpatient and after discharge palliative care is essential to improve quality of end-of-life. Critical limb ischemia is associated with an excruciating pain. We describe the successful in-hospital and after discharge use of perineural sciatic nerve catheter to control refractory ischemic pain.

Data was collected through consultation of clinical records.

Case report: A 77-year-old female was admitted with decompensated heart failure (NYHA class IV) and respiratory failure requiring non-invasive ventilation. Medical history included atrial fibrillation, severe aortic stenosis, arterial hypertension, obesity, poorly controlled diabetes mellitus and bilateral chronic lower limb ischemia. Physical examination revealed necrosis of the right foot and ulcerations on the left one. Surgical treatment was refused, and conservative/confort measures were adopted. Despite morphine intravenous infusion, severe pain at rest and during wound dressing was referred. Chronic pain unit consultation was required, and continuous sciatic popliteal nerve block was proposed. Immediate relief was reported after the first bolus and a DIB with ropivacaine was initiated. Given the bad clinical prognosis and patient’s desire for home discharge, patient went home with perineural popliteal DIB of ropivacaine 0.1% 5mL/h (replaced every 3 days at the chronic pain unit) and fixed 5mg oral morphine including before wound dressing, performed by the primary healthcare team. Excellent pain efficacy (EN 2/10) and high level of patient and family’s satisfaction were reported.

Home-based palliative care decreases readmissions and health care utilisation. Locoregional analgesia may be an effective tool establishing the bridge between acute and home-based palliative care for management of chronic pain at end-of-life patients.

Peripheral neuropathies are a relatively common complication after CABG surgery, occurring in about 10-15%. Most frequently affected nerves are the brachial plexus, phrenic nerve, recurrent laryngeal nerve, and saphenous nerve. Similarly, after cardiac catheterization with transfemoral access (TFA), the incidence of limb dysfunction ranges from 0.004% to 0.21%, with thigh cutaneous nerves being affected in 0.04% of cases.

ASA3, 51-year-old female with PMH: coronary artery disease who underwent redo-CABG with femoral vascular cannulation for cardiopulmonary bypass post-NSTEMI, under GA. The surgery was uneventful, but on POD2, the patient complained of moderate neuropathic pain in her right thigh, which worsened with movement and preventing ambulation. Examination revealed sensory deficits in the distribution of the intermediate cutaneous nerve of the thigh (ICNT), no motor deficit. Increasing pregabalin dose, didn't provide relief. An USG-ICNT block successfully alleviated the pain, the patient was discharged with mild pain under medication.

The ICNT is a branch of the femoral nerve and is vulnerable to injury during TFA. Symptoms typically manifest with a delay of approximately 37 hours and include sensory deficits and severe pain. Motor neuropathy may also occur. The exact cause of nerve injury is multifactorial. Prompt recognition and appropriate management are crucial for optimal patient outcomes, avoiding unnecessary suffering and potential discharge delays.

Conclusion: Surgeons should be mindful of the potential for ICNT injury during inguinal cannulation in redo-CABG procedures. Early diagnosis and effective pain management are essential in ensuring the best possible outcomes for patients. 10.1055/s-0043-121628 10.1253/circj.CJ-18-0389 (Circ J 2018; 82: 2736–2744) 10.1016/B978-0-444-63599-0.00031-4

The purpose of this study is to describe a patient with knee osteoarthritis (KOA), where both pharmacological and non-pharmacological regiments proved inadequate and could not undergo surgery for total joint replacement (TJR). At this dead-end, intra-articular (IA) combination of various agents was applied aiming for a multifactorial approach. Currently there is no literature regarding similar treatment.

A 81 years old female with KOA was treated gradually with paracetamol, diclofenac and later with tramadol/dexketoprofane but reported minimal improvement of her condition after two months. After IA injections of hyaluronic acid initially and platelet-rich plasma later seemed to offer no results, an IA combination of fentanyl 50mcg, dexamethasone 8mg, clonidine 150mcg, ropivacaine 7.5% 5ml dextrose 30% 5ml and natural saline 0.9% 5ml was applied after the patient’s informed consent.

The treatment led to pain absence that lasted for about two years.

As the patient was not eligible for IA Stem Cells or TJR and was non responsive to both pharmacological and invasive treatments, the resulting dead-end urged for improvisation. The multifactorial approach seems to offer satisfactory and encouraging results as the quality of life improvement helped the patient not only physically but also psychologically. The authors now plan to perform a randomized control trial using the aforementioned agents in order to assess the results in a larger scale.

The purpose of this study is to describe a patient with knee osteoarthritis (KOA), where both pharmacological and non-pharmacological regiments proved inadequate, and could not undergo surgery for total joint replacement (TJR). At this dead-end, an intra-articular (IA) injection of a combination of various agents was applied aiming for a multifactorial approach. Currently there is no literature regarding similar treatment.

An 81 years old female with KOA was treated gradually with paracetamol, diclofenac and later with tramadol/dexketoprofane but reported minimal improvement of her condition after two months. After IA injections of hyaluronic acid initially and platelet-rich plasma later seemed to offer no results, an IA combination of fentanyl 50mcg, dexamethasone 8mg, clonidine 150mcg, ropivacaine 7.5% 5ml, dextrose 30% 5ml, and natural saline 0.9% 5ml was applied after the patient’s informed consent.

The patient reported complete pain absence for nine months, rare and mild pain attacks for the following 11 months, and insurgence of her algologic condition after that. Nevertheless, she described her condition as being better than before the injection.

As the patient was not eligible for IA Stem Cells or TJR and was non responsive to both pharmacological and invasive treatments, the resulting dead-end urged for improvisation. The multifactorial approach seems to offer satisfactory and encouraging results as the quality of life improvement helped the patient not only physically but also psychologically. The authors now plan to perform a randomized control trial using the aforementioned agents in order to assess the results in a larger scale.

Temporomandibular disorders (TMDs) are a frequent cause of orofacial pain, causing functional disability and a negative impact on quality of life. Incobotulim toxin A -Xeomin- (BTX-A) injection in lateral pterygoid muscle (LPM) is one of the treatment modalities proposed, but the blind puncture guided by EMG carries a risk of vascular puncture or diffusion of the toxin to nearby muscles. We describe an ultrasound-guided approach and show the results of a retrospective study of thirty patients.

Thirty patients with unilateral temporomandibular myofascial pain were treated. An out-of-plane approach was performed using a convex probe, injecting 20 U of BTX-A (2.5 unit/0.1 ml solution – 0.8 ml) into the LPM. Before puncture, using colour Doppler mode, the maxillary artery was located to avoid its puncture.

Compared with baseline, patients manifested significant improvement in pain (VAS) at rest and at mandibular movement a month after treatment (p<0.05). Temporomandibular joint (TMJ) click was present prior to treatment in twenty-four patients, disappearing in 16 of them a month after injection (66.7%). No complications were detected during or after treatment.

An ultrasound-guided approach for the injection of BTX-A into the LPM could be considered a successful and safe treatment for myofascial pain related to TMD and TMJ clicking. Therefore, further studies with larger sample sizes and longer follow-up periods are needed to study the effect of BTX and its long-term effects.

Lumbar sympathetic block is a recommended treatment for post amputation stump pain. Here we present a case complicated by retroperitoenal hematoma due to lumbar artery injury.

A 69-year-old man had a below-knee amputation because of trauma 25 years ago and had severe stump pain that had been increasing for 1 year. Medical treatment was not sufficient and he was scheduled for right lumbar sympathetic block and radiofrequency procedure. Right L2 and L3 lumbar sympathetic block and pulse radiofrequency was performed. L4 lumbar sympathetic blok was attempted but was not successful due to encountering nerve root.

After 6 hours patient applied to emergency service for severe right leg and groin pain and dizziness. On examination, abdominal distension, defense and rebound were observed and Hb decrease was detected in blood tests. During follow-up in the emergency room, hypotension and confusion developed. Computed tomograpy revealed right retroperitoenal hematoma. The patient was taken to the post-anesthesia care unit and angiographic imaging was planned as an emergency. Selective right lumbar artery angiography and embolization were applied to the L4 level by the interventional radiology team. Control abdominal ultrasound revealed no active bleeding. The vital signs of patient was stable and discharged after 2 days. He had no pain but nausea and fatique. Follow up for hemodynamic state is going on.

Interventional pain procedures around spine demand extra care to avoid the aorta related vascular structures. Lumbar artery injury after sympathetic block is a rare complication and selective anjography and embolisation is a life saving procedure.

Hiccups, which can be quite debilitating, have been reported after interventional pain procedures (IPPs); however, the association between the two remains unexplored.

A comprehensive search was carried out in PubMed, Cochrane, Ovid, and DOAJ to identify case reports and case series reporting the occurrence of hiccups after IPPs since inception to May 27, 2023. Two reviewers parallelly screened the studies using predetermined inclusion and exclusion criteria. After quality assessment, a standardised template was used to extract data from each study, including study characteristics and type of IPP; approach, region, and drugs used in the procedure; management details; and outcome. A descriptive analysis of the extracted data was then carried out. Chi-square tests of association and Fisher's exact tests were conducted where appropriate.

147 articles were screened, out of which 130 were excluded, and thus, a total of 17 articles containing 24 case studies were finally included in the review (Figure 1). Among the various IPPs, epidural injections were responsible for the highest number, i.e., 18 (75%) cases of hiccups, 10 (55%) of which were given in the lumbar region. A combination of steroids with local anaesthetics was the most frequent culprit leading to hiccups, wherein betamethasone and dexamethasone, and lidocaine and bupivacaine were the most common steroids and local anaesthetics, respectively (Figures 2 and 3). Two-thirds of the cases required pharmacotherapy for the resolution of the hiccups.

Hiccups should be acknowledged as an adverse effect following IPPs, requiring the formulation of a protocol for their management.

Lumbar disc herniation is a common pathology that may cause significant low back pain and radicular pain that could profoundly impair daily life activities of individuals. Patients who undergo surgical treatment for lumbar disc herniation usually present with radiculopathy along with low back pain(LBP) instead of radiculopathy alone.1 When discectomy is performed, improvement in leg radiating pain is observed due to spinal nerve irritation. However, long-term LBP due to degenerative changes in the disc may occur postoperatively. In addition, limited research has been reported on the short-term (within 1 year) improvement in LBP after discectomy. We would like to share our minimally invasive open technique for lumbar discectomy with annuloplasty and nuceloplasty as a technique for effective reduction of both axial and radicular pain.

As the case presentation is devoid of patient identifiable information, it is exempt from IRB review requirements as per Precision Pain & Spine Institute policy

Minimally invasive lumbar discectomy along with nucleoplasty and annuloplasty with SVN cauterization can result in significant and long-term relief of both axial and radicular pain.

There is limited research on the improvement in LBP after discectomy. It is documented that low back pain improved within the first 3 months postoperatively and plateaued afterward. Nucleoplasty produced statistically significant improvements in pain, functional disability and quality with discogenic LBP. of life in patients with discogenic low back pain at 6 months and at 12 months. Based on theoretical SVN conduction studies, the use of SVN block can reduce pain in patients.

Chronic pain management is one of the greatest worldwide concerns and an innovative alternative that shows a great potential therapeutic effect in the geriatric population is neuromodulation. The purpose of this abstract is to highlight some of the most important neuromodulation techniques that effectively manage chronic pain. In order to reduce the sensations of pain, neuromodulation includes the focused modulation of neuronal activity via electrical, magnetic, or pharmacological stimulation. Spinal cord stimulation, peripheral nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation are some neuromodulation treatments that have been developed which each target certain regions of the nervous system.

The most recent clinical research supporting the use of neuromodulation in the treatment of chronic pain is reviewed in this abstract, with a focus on RCTs, literature review, meta-analyses, and systematic reviews.

To achieve better results, some important parameters were taken in consideration such as age-related conditions, comorbidities, pain assessment, cognitive-psychosocial factors, toxicology, long-term outcomes, etc. Based on these parameters and methodology, literature demonstrated a great deal of efficacy in reducing pain for the long term and enhancing patients quality of life. Neuromodulation works by changing neurotransmitter release, altering pain transmission routes, and inducing neuroplasticity.

Technological developments guarantee more accuracy of neuromodulation therapies. As a non-pharmacological treatment for chronic pain, neuromodulation has enormous potential to provide a specialized and focused approach to pain management. However, more research in this field is essential to optimize protocols, include more parameters, and refine the understanding of neuromodulation mechanisms to achieve better pain relief outcomes.

Here we present a forty-five-year-old, right hand dominant male who suffered a traumatic right forearm crush injury while using a cement mixer. Following multiple orthopedic procedures and superficial radial nerve neuroma excision, he developed chronic neuropathic pain in his right forearm. He was refractory to conservative treatments and continued to experience this pain for fifteen years before being referred to our Pain Clinic. He reported that the ongoing pain affected his quality of life and hindered his occupation as a welder.

His exam was consistent with a right radial nerve mononeuropathy and he was offered a temporary peripheral nerve stimulator (PNS). Ultrasound was used to identify the right radial nerve 10 cm proximal to the patient’s elbow. Local anesthetic was used to numb the desired entry site, with care taken to avoid administering local anesthetic near the target site which can obscure response to neurostimulation. Following successful test stimulation the lead was deployed. Repeat stimulation and ultrasound imaging confirmed successful placement, and following device management education, the patient was discharged.

The patient achieved complete resolution of his neuropathic pain during 60-day stimulation and sustained relief at one year follow-up.

Peripheral nerve stimulation should be considered for patients with neuropathic pain in which the target nerve can be identified. Interventional pain physicians should work to further disseminate the utility of PNS in hopes that future patients do not have to suffer for 15 years before being referred to a pain clinic.

Low back pain due to lumbar radiculopathy is the cause of significant disability. Epidural steroid injections with or without local anaesthetic are often prescribed to patients who are not responding to conservative management. Epidural injections may carry the attended risk of neurological injuries. We hypothesized that the nociceptor fibres being pseudo – unipolar in nature, with both ends behaving functionally the same. The peripheral nerve blocks administered distally should be as effective in providing pain relief.

The thirty-four patients who had been recruited in the single-arm study were followed up at 6 months and 12 months post the intervention and the outcomes were noted. They had been administered peripheral nerve blocks at ankle level with 4ml of 0.25% bupivacaine and 40mg of triamcinolone. Outcomes measured: The outcomes measured at 6 and 12 months after the intervention were the pain intensity (Numerical Rating Scale), the Global Perceived Effect, employment status, and analgesic intake.

Out of 34 patients, 4 had dropped out at 6 months and 12 at 12 months. Statistical analysis of the data showed a significant decrease in pain intensity (p<0.001). There was also a significant improvement in both the employment status and the analgesic intake and no additional side effects were reported by any of the patients.

This present study shows that peripheral nerve blocks are effective in the management of pain in patients with lumbosacral radiculopathy even in the long term (1 year) with no significant adverse effects.

Patient after a fall with right craniofacial-cervical trauma. Diagnosed with cervical spine straightening and C5-C6 disc protrusion. Reports persistent left cervicobrachialgia. Studies reveal left humeral tuberosity fracture and tendinitis. Despite rehabilitation, referred to pain consultation due to symptom persistence.

Physical examination shows atrophy of the left trapezius and sternocleidomastoid muscles, along with reduced strength in the upper and middle trapezius (Fig.1). Post-vaccination Parsonage-Turner syndrome or accessory spinal nerve injury is considered. Electromyography reveals moderate to severe partial axonotmesis of the left accessory spinal nerve (Fig.2). Magnetic resonance imaging shows extensive neuropathy along the nerve pathway (Fig.3). The patient receives conservative treatment with analgesics, corticosteroids, pregabalin, clonazepam, and intensive rehabilitation. Significant improvement in pain and muscular recovery is observed at 6 weeks. Electromyography at 8 weeks demonstrates increased amplitude of the motor evoked potential, indicating progressive and adequate reinervation. In conclusion, accessory spinal nerve injuries are uncommon after mild trauma and are typically associated with oncological surgery. Initial treatment should be conservative, considering surgical options only if conservative treatment fails. Additionally, the use of platelet-rich plasma may hold promise in the treatment of such injuries. Comprehensive physical examination and appropriate ancillary tests are essential for accurate diagnosis and proper management, as pathological imaging does not always explain clinical findings.

Hip osteoarthritis management primarily focuses on rapid symptom control including pain alleviation and functional improvement. Ultrasound-guided regional anesthesia techniques targeting the branches of the anterior lumbar plexus have been performed in providing pain relief in chronic hip pain. However, despite these approaches, patients may experience residual posterior hip pain, which can be attributed to the posterior nerve supply of the hip. We present a case report of chronic hip pain successfully managed with posterior pericapsular deep-gluteal (PPD) block in addition to pericapsular nerve group (PENG) block.

A 56-years old patient with a history of total hip arthroplasty presented to our pain clinic. Inspite of medication and physiotherapy management, the patients' numeric rating score was 6 at rest and 8 during movement. After three repeated PENG blocks within a one-month period, the pain localized to the posterior hip region. Consequently, we decided to perform PPD block (Figure 1). Written consent was obtained from patient for the procedure and future publication.

After administering the PPD block in addition to the PENG block, the patients' NRS scores decreased to 2 at rest and 4 during movement. Additionally, the patients' functional capacity scores showed improvement (Table 1).

An additional PPD block can be beneficial in patients with residual posterior hip pain, even when anterior approaches have been performed. We suggest that PPD block targeting the superior gluteal nerve, nerve to the quadratus femoris muscle, and sciatic nerve in addition to the PENG block can be performed for more complete analgesia in chronic hip pain.

Back pain is a very common pathology in Chronic Pain Units, often induced by lumbar disc herniation. Different therapeutic interventions have been studied, being conservative measures first-line treatment. Oxygen-ozone injections are becoming more common as an alternative therapy but its efficacy in terms of pain relief and functional improvement is uncertain. Even though it is considered a minimally invasive technique, potential complications such as hematoma, local infections or nerve irritation, have been described.

We present a case of a patient who suffered a posterior reversible encephalopathy syndrome (PRES) secondary to a subarachnoid embolism after oxygen-ozone injections, a side effect non-previously reported in the literature.

83-year-old woman, with general arthrosis and chronic back pain secondary to herniated disc, electively submitted to oxygen-ozone intradiscal injection in an outpatient clinic. Immediately after the injection, she suffered a sudden decrease of consciousness and was transferred to our hospital. She presented a Glasgow Score of 8, global aphasia, right oculocephalic deviation, right upper extremity claudication and bilateral babinski sign. An AngioCT scan showed two air bubbles in subarachnoid sulci of the left frontal and parietal lateral convexity with subcutaneous emphysema. She was intubated, transferred to ICU and received two hours of hyperbaric therapy. Magnetic resonance showed probable PRES secondary to oxygen-ozone encephalic embolism. Afterwards, she could be extubated with no neurological sequelae.

Oxygen-ozone injections as intradiscal therapies, have multiple associated complications that must be taken into account when assessing risks and benefits. Further studies are needed to evaluate outcomes and associated complications.

Dorsal scapular nerve(DSn) entrapment syndrome is a relatively unknown cause of neck and shoulder pain. The DSn arises from the C5 nerve root, with a possible contribution from the C6 nerve root; it pierces the middle scalene muscle and travels posteriorly to innervate the levator scapulae, rhomboid major and minor muscles.

A 29-year-old male, presented with neck discomfort and significant left shoulder pain, along the inner part of his scapula. The patient reported a VAS-score between 6-10/10, deteriorating over the past 4 years; the pain remained untreated despite oral multimodal analgesia. He also reported a subtle scapula winging feeling (not evident during clinical examination). Cervical MRI revealed a small left disc bulge at C6-C7, brachial plexus MRI was unremarkable, EMG of his left arm showed damage of sensory nerves (radial, median, and lateral cutaneous nerves of the forearm), chronic neurogenic changes of left C5-C6 and elements of active denervation of left C8-T1.

After performing a diagnostic block on his left DSn (4mg dexamethasone and 5mg ropivacaine), the patient reported 100% pain relief, so we proceeded to pulsed radiofrequency(pRF) of the nerve. (22G_50mm_5mm active tip needle, pRF cycle:240sec at 42C). Three months after his treatment he reports a 90% pain relief.

Dorsal scapular nerve entrapment is an uncommon diagnosis but must be considered in young patients presenting with neck and shoulder pain. While performing the diagnostic block is relatively easy, pRF requires stability of the needle throughout testing and treatment, which might prove challenging for the performing clinician.

The analgesic cornerstone in cancer pain are opioids(1), in some cases interventional-pain-management is recommended(2). The Quadratus lumborum block(QLB) has shown benefits for abdominal wall(3), parietal and neuropathic pelvic pain(4). Its analgesic extends effect from T7-L1(5) this is explained by the relationship between the transverse fascia and the endothoracic fascia(6). Safety of phenolization has been described in cancer(7). We present a case report of QL2 phenolization for cancer pain.

This is a case of a 66-year-old male patient with malignant colonic cancer, metastatic to pancreas, spleen and abdominal wall, with intractable severe pain. A diagnostic QLB-2 was proposed because he refused any continuous neuraxial procedure. We proceeded under ultrasound-guide, in plane with a sham-rock approach, with 20mL bupivacaine 0.5% with 50 mg of triamcinolone(Fig 1A). After 48 hours a neurolytic phenol injection was administered, with identical technique only bupivacaine was replaced by 20ml phenol 10%.(Fig 1B).

The patient’s reported 70% d dynamic and 80% on static decrease in pain on VAS for 48 hours and 42% oxycodone daily dose reduction with QL-2 block, 80% decrease in dynamic and 90% at rest pain during 10 days and 40% reduction in oxycodone dose with neurolysis. Unfortunately, due cluster symptoms he required intermittent sedation 2 weeks and past away.

This case is a novel use for QLB-2 as an anatomical target for neurolytic procedures for abdominal cancer pain relief. Further trials are needed for to highlight the role of this procedure for a more widespread use.

Complex regional pain syndrome (CRPS) is a chronic pain disorder, usually involving hyperalgesia and allodynia of the extremities. The exact mechanism is unknown, although several different mechanisms have been suggested. The diagnosis is clinical. Regional Anaesthesia can play an important role in treating the pain in these patients who will thus be able to carry out the correct physiotherapy.

This study is a case series of 7 children with a diagnosis of CRPS, aged from 8 to 15 years, that received specific continuous nerve blocks. The 70% of these patients presented symptoms to lower limbs, while only the 30% had an involvement of upper limbs. During the first objective examination, all the children showed a considerable decreased range of motion (ROM) of the interested extremity, meanwhile a change in sensitivity and temperature was observed, besides hyperalgesia, allodynia, redness, oedema. After a multidisciplinary discussion, every child was treated with physical therapy, previous placement of ultrasound- guided perineural catheter.

After this intervention all the children were able to perform physical therapy without pain. At the end of therapy program, an increase of ROM was observed, besides a reduction of Number pain rating scale (NPRS).

Two persons of this group had a recurrence of acute episode after six months; they were treat in the same way, but only one of them had a benefits. The other one was a 12 years a young woman that had particular psychological characteristics, such as kinesiophobia for this reason she followed a psychologic and cognitive- behaviour treatment.

Developing a multidisciplinary approach for nerve pain treatment involves dosimetry, nanobots, and artificial intelligence (AI). Dosimetry calculates radiation dosage to determine the optimal treatment dose based on patient factors. Nanobots target nerve cells or pain receptors, improving precision. AI analyzes patient-specific data to optimize treatment plans. The aim is to revolutionize nerve pain treatment by leveraging dosimetry, nanobots, and AI. Dosimetry ensures personalized treatment, nanobots target specific cells, and AI optimizes plans.

Methods include patient evaluation, dosimetry planning, nanobot design, treatment administration, AI analysis, and treatment refinement. Patient evaluation considers medical history, imaging, and pain intensity. Dosimetry determines optimal dosage. Nanobots are designed to target cells, administered with imaging guidance. AI analyzes dosimetry, imaging, and nanobot data to optimize treatment. Treatment plans are refined based on AI analysis.

Results show promising integration of dosimetry, nanobots, and AI. Dosimetry allows personalized treatment, nanobots enhance precision, and AI optimizes strategies.

In conclusion, the multidisciplinary approach of harnessing dosimetry, nanobots, and AI revolutionizes nerve pain treatment. By providing personalized relief through optimized treatment plans, this approach has the potential to significantly improve the quality of life for individuals suffering from nerve pain.

Continuous peripheral nerve blocks are an alternative for analgesia in situations where a single dose of local anesthetic is insufficient. There are numerous indications for this type of block, including phantom limb pain.

We present the case of a 35-year-old man, with no medical history of interest, who suffered trauma in the left arm with multiple fractures and section of the left brachial artery. Supracondylar amputation of that arm was performed. In the immediate postoperative period, the patient presented intense pain (VAS scale of 8 that did not respond to NSAIDs or intravenous opioids) of the upper extremity, for which it was decided to place a supraclavicular catheter with continuous infusion of 0.2% ropivacaine, with good pain control, associated with intravenous analgesia. 24 hours later, the patient reported a sensation of phantom limb pain in the amputated region, so 300 mg of Gabapentin were added to the treatment.

Phantom limb pain appears in up to 80% of amputee patients. 75% of patients who develop it do so in the first week after amputation. Perineural blocks have been described as a good alternative for the treatment of phantom limb pain, as well as for acute pain after amputation surgery.

Despite the numerous interventions that are proposed for the treatment of phantom limb pain, there is no single treatment that is completely effective, which is why multimodal treatment is necessary. Disabling phantom limb pain usually decreases in intensity over time, so an early approach allows better pain control in its early stages.

Intraoperative nerve injuries caused by the patient’s positioning are surgery’s undesirable complications, that might occur despite preventive measures and lead to sensory and motor deficits and neuropathic pain. This work aims to describe a clinical case of a patient who developed neurological deficits in the territory of the common peroneal nerve (CPN) after a meningioma’s excision. The patient gave consent to this clinical case presentation.

A 49-year-old woman underwent a temporal meningioma removal. In the postoperative period, the patient developed incapacity of dorsiflexion of the feet bilaterally and intense neuropathic pain (8/10), with a daily sensation of electric shocks and burning. The electromyography test revealed signs of bilateral involvement of the CPN, above the peroneal head, with severe axonal damage, more significantly at the left side. The patient was initially prescribed with a therapeutic plan that included gabapentin and physiotherapy, showing mild benefits. However, although presenting a moderate improvement of the neuropathic pain, the patient maintained a relevant and disabling clinical condition. Therefore, a peroneal nerve block (PNB) was proposed.

The patient underwent an ultrasound-guided bilateral PNB, administering 2 ml of 0.2% ropivacaine and 20 mg of methylprednisolone on each side. The patient described an immediate improvement in the neuropathic pain score (2-3/10) and could walk without crutches. In the following months, the patient referred a sustained improvement in the pain score and autonomy.

These results show that ultrasound‐guided blockade using 0.2% ropivacaine and methylprednisolone could be a safe and effective treatment in patients with nerve injury and neuropathic pain.

Transforaminal Epidural steroid injection is an extremely valuable tool in the conservative management of cervical radicular pain. For decades this injection has been performed under fluoroscopic guidance and while complications are serious and infrequent, this imaging technique cannot prevent inadvertent arterial puncture. Considering delicate cervical anatomy, ultrasound may bring a valid alternative, allowing for real time needle advancement, at no radiation expenses. Recent medical studies have supported the use of Ultrasound as a pivotal imaging tool and as an alternative to the gold standard of this procedure. The aim of this presentation is to illustrate the Cervical TESI, comparing the ultrasound to the already consolidated imaging tool.

This review describes advantages and disadvantages of US guided cervical epidural steroid injection techniques compared to the fluoroscopic guidance, as encountered in the recent medical literature.

Despite the lack of foraminal flow visualization, recent medical studies have demonstrated correct target identification with immediate and long-term effectiveness of extraforaminal (periradicular) US guided steroid injections. A higher volume showed an increase in the foraminal flow, without modifying the outcome. Also, recently, a new technique of US guided transforaminal epidural injection has been described and investigated.

Ultrasound guided injections have several meaningful advantages over any other imaging technique, providing real time visualization and possibly preventing inadvertent vascular canulation. However, the US guided technique cannot demonstrate utility regarding the posterior foraminal vasculature, thus still relying on aspiration and fluoroscopic confirmation. Until further research, a combination of both US and Fluoroscopic guided techniques remains the recommended approach.

Superior cluneal nerves (SCN) originate from the dorsal rami of lower thoracic and lumbar spinal nerves by their lateral cutaneous branches and provide sensory innervation of the posterior iliac crest, superior gluteal region and greater trochanter. A reliable SCN block may have application in management of chronic lower back pain, which has a high prevalence and frequently a neuropathic pain component. In this case report, we describe the use of ultrasound-guided SCN block technique for the management of chronic neuropathic post-herpetic pain located on lower back and gluteal region, refractory to initial pharmacological and topical treatment strategies.

Male patient, 39 years-old presents with post-herpetic neuralgia and complaints of unilateral lower back and gluteal pain, with allodynia, burning and stabbing in affected area, NRS 6 and DN4 questionnaire 6/10. Initial pharmacological treatment with amitriptyline, gabapentin and tramadol with no adequate pain relief. Three topical capsaicin attempted with only partial relief, so an ultrasound-guided SCN block was performed with ropivacaine 0,2% and triamcinolone, with mapping of cutaneous allodynia area. Minutes after nerve block there was a significant reduction of the area, with pain intensity successfully decreased.

Neuropathic pain is a major form of chronic pain with profound physical and psychological impact and it's often challenging to manage due to its diversity of mechanisms and patients’ responses. In this case the SCN block provided the patient an effective pain relief due to the nerves contribution to the affected area, perhaps underlying a neuropathy-mediated SCN pain, which may benefit of longer relief with radiofrequency.

Cancer pain is most of the times relieved by pharmacological treatment. When pharmacological treatment is not sufficient, interventional pain procedures are considered. Here we present a case complicated by epidural hematoma.

58 years old female patient with stage 4 metastatic colon and urethelial carcinoma was referred to our clinic for hip and leg pain. She had multiple bone metastasis. Medical treatment was not enough, so transforaminal epidural steroid injection (TFESI) and lumbar sympathectomy was offered. The needle was fluoroscopically aimed for left L2 TFESI through the “safe” triangle. Needle insertion happened to be intravascular with spontaneous return of blood. It was decided not to proceed further with the injection. Other interventions were performed uneventfully.

12 hours later, the patient experienced left-sided sensorimotor loss. Left lower extremity examination revealed 0/5 motor functions of left hip and knee extension and flexion with hypoesthesia from T10 to L2 dermatome were noted. Sensorimotor function of the right lower extremities were normal. Urgent thoracolumbar MRI revealed left sided epidural hematoma extending from T8 to L2 (Figure 1). Emergent epidural hematoma decompression surgery was offered, which she declined due to her comorbidities.

Although lumbar TFESI was found to be safe, we experienced an epidural hematoma, which we believe was because the “safe” triangle approach was chosen, where blood vessels lie. To our knowledge, our case is the first one to report unilateral paresis following a massive epidural hematoma. We believe, Kambin’s triangle approach may prevent from, a rare but debilitating complication, epidural hematoma.

Shoulder-pain is identified as the second most common MSK complaint, requiring a multimodal interdisciplinary approach. Among the multiple techniques used for the management of chronic/intractable shoulder-pain, neurolysis, despite having been used for over a century(2), has not described for the management of this type of pain. We aim to describe the safety and efficacy of phenol-neurolysis used for shoulder pain.

We present the case of a 65-year-old female with a PMH of cerebellar-ataxia, with progressive-motor-degeneration. She became bed-bound, leading to a spontaneous-shoulder-luxation, no surgical approach was recommended due to her poor neurological-condition. Posteriorly she presented moderate-severe static-pain(SP), severe dynamic-pain(DP) and limitation for the abduction of the shoulder to 40°. After discussion, a phenol-denervation using a motor-spearing approach was proposed. Due to her limited mobility, no diagnostic-block was performed. Under ultrasound-guidance we approached the suprascapular-nerve at 2-locations(figure-2), the axillary-nerve(Figure-3) and the lateral-pectoral-nerve(figure-4) depositing 6%phenol, 1cc at each target, using motor-spearing-techniques proposed by Peng-et-al(3)

Immediately after the procedure a 100% percent reduction in static pain and 90% in dynamic-pain was observed, with a 60° increase in shoulder-abduction-range. One month after the procedure the patient refers 100%-SP reduction and 60%-DM reduction with a conserved range of motion.

Motor-spearing-techniques using neurolytic-blocks have not been broadly reported at the shoulder-joint. In these cases, due to the low functional-class this block was selected over other neurolytic blocks. As shown in other joints by Risso-et-al(4), low dose neurolytic blocks can be effective in such articular targets can be effective for refractory shoulder pain using motor-spearing-approaches.

Syringomyelia is characterized by the presence of spinal cord cavitation. It has multiple causes and is most commonly seen in association with Chiari I malformation. In these patients, the distribution of symptoms sometimes correlates with the anatomical location of the spinal cavitation. Dysesthesia is found in slightly less than half of the patients and it responds unpredictably and often poorly to currently available treatments. We present a case in which the dysesthesia could have been attributed to cervical syringomyelia, but the cause of this spinal finding remained elusive.

36-year-old female with history of Meniere's disease and carpal tunnel syndrome presenting with numbness and tingling in her right arm and bilateral lower extremities for 1 year. She also reports having pain in her right arm, but not her legs. An MRI of the cervical spine showed central and right paracentral cervical spinal cord edema with small caliber syrinx from the levels of upper C3 through C6/7, moderate sized syrinx with the right hemi cord at C7 and partially visualized large multiseptated syrinx within the upper thoracic spinal cord from T1-T4. Her brain MRI ruled out Chiari's malformation. A thoracic MRI found continuation of the syrinx and a mass at the level of T9. The patient underwent resection of the mass.

Spinal cord ependymoma is a rare tumor and surgical resection has been established as first-line treatment and can be curative. This case illustrates that a complete spinal MRI is advisable when symptoms partially match the anatomic location but not the cause.

Hip fractures in young individuals and children often occur due to high-energy injuries such as traffic accidents or falls from heights, often accompanied by polytrauma. Managing the intense pain in these patients and ensuring hemodynamic stability calls for a multimodal approach to pain control, both during surgery and throughout their stay in the ICU. External fixation through the traction method is typically employed to stabilize the patient's leg. We present a 16 years old polytraumatic patient with a hip fracture who also had a medical history of chronic use of psychoactive substances. The patient had a diagnosis of schizophrenia and was receiving aripiprazole therapy. The patient's chronic use of psychoactive substances, in combination with the synergistic effect of opioids, tramadol, and aripiprazole, posed a risk for tolerance development, necessitating the exploration of alternative methods for analgesia.

We utilized an ultrasound-guided femoral nerve catheter to administer a continuous infusion of Ropivacaine 0.125% at a rate of 6ml/h. Assessment of the level of analgesia was done using pain scales- VAS,NRS.

During the patient's ICU stay, no additional intravenous analgesics were required, except for the standard pain relievers supplemented with non-steroidal anti-inflammatory drugs

The femoral catheter proved to be a simple, effective, and relatively safe method of analgesia. The ultrasound-guidance of the technique allowed for precise monitoring of local anesthetic spread, needle and catheter placement, and helped mitigate potential risks and complications.It represents a favorable choice for providing analgesia in polytraumatic patients with hip fractures and risk of opioid tolerance

Electroconvulsive therapy (ECT) is a controlled electrical stimulus that affects central nervous system and leads to convulsion. Such as every other medical procedure, electroconvulsive therapy has some side effects like headache and myalgia. Patient undergoing electroconvulsive therapy receives deferent anesthetic drugs and some drugs like Midazolam, Atropine etc. to reduce side effects.

This study included 40 patients who were candidates for receiving electroconvulsive therapy. By using convenience sampling, patients were divided into 2 groups of 20 people. Midazolam were given to one group while the other received placebo. Two patients in midazolam group were removed because of short period of convulsion (lower than 20 seconds). The collected data were analyzed using independent t and chi-square tests.

16 men (42.1%) and 22 women (57.9%) were studied. The incidence of headache (P < 0.001), myalgia (P = 0.014) and vomiting (P = 0.011) was significantly higher in witness group. The incidence of coughing and laryngospasm was not significantly different between the two groups (P > 0.050).

Midazolam can reduce convulsion time but in most cases, convulsions last more than 25 seconds, which is in therapeutic range. So, it cannot affect the therapeutic value of electroconvulsive therapy. Preemptive midazolam reduces Post-electroconvulsive-therapy headache and myalgia.

Introduction Regional anesthesia techniques (thoracic, epidural, paravertebral) in non cardiac thoracic surgery enhances perioperative analgesia, early extubation and shorten hospital length of stay. However the failure rates and risk of pneumothorax causes these techniques sometimes avoided among Pediatric population. Ultrasound guided Serratus Anterior Plane Block (SAPB) is an alternative that provide satisfactory perioperative analgesia for infants undergoing non-cardiac thoracic surgery.

An 1 year old 9kg infant was diagnosed with congenital multicystic lung lesion of right upper lobe planned for open right thoracotomy. With informed consent ,he was planned for operation under general anaesthesia with right SAPB. He was induced with with IV Fentanyl 10mcg, IV Propofol 20mg and IV Atracurium 4mg. On the left lateral position, Ultrasound guided SAPB was done prior surgical incision with Sonoplex Pajunk 50mm and 4mL of Levobupivacaine 0.25% ( 10mg ) injected in between Serratus muscle and Latissimus dorsi muscles at level of T5 . Intraoperatively, IV Paracetamol 135mg (15mg/kg) and IV Morphine 0.2mg was given as additional analgesic during manipulation and resection of the lung parenchyma. His hemodynamic were stable through out the surgery. Post operatively, patient was transferred to PICU and ventilate overnight with IV Morphine 50mcg / hour as sedation. He was extubated to nasal prong 2 litres/min subsequent day. He was transferred to general ward after 3 days stay in PICU and was discharged well after 7 days of hospitalisation.

Ultrasound guided Serratus Anteriod Plane Block (SAPB) is and effective, simple, relatively safe analgesic adjunct for infants undergoing non-cardiac thoracic surgery

Ewing's sarcoma (ES) is a high-grade malignant bone tumor, peaking at the teenage years, predominantly in long bones. It is rarely located in the scapula, with 9 of the 15 cases published in the literature occurring in children. We describe here the analgesic plan and outcome for a case of total scapulectomy in a six-year-old female (after completion of the standard ES radio- and chemotherapy protocol), combining elements of regional anaesthesia as part of multi modal analgesia. Analgesic options for this operation are anatomically challenging and their outcomes have been sparingly described in the literature, mostly in adults.

Intraoperatively we chose a combined neuraxial (T3/4 thoracic epidural) and peripheral (posterior tunneled interscalene) continuous catheter approach, as well as multiple opioid sparing techniques (ketamine and dexmedetomidine infusions). A superficial cervical block would not have added a major analgesic benefit to the catheters. The interscalene catheter became displaced during transport to the intensive care unit. We continued epidural treatment for 6 days, with parent-controlled boluses, supplemented with a continuous infusion of morphine, scheduled paracetamol, ketorolac and metamizole combined with gabapentin.

Satisfactory intraoperative analgesia was achieved with the combination of catheters using a single bolus of fentanyl at induction. The epidural boluses were reported effective by the patient and parents for breakthrough pain.

The combination of neuraxial and regional analgesia was beneficial intraoperatively. Epidural patient controlled analgesia was effective in the early post-operative period, as part of multi-modal analgesia. This treatment enabled a rapid and calm recuperation considering the extent of the surgery.

Epidural anesthesia is established as a standard in global medical practice. Caudal anesthesia is a specific case of epidural anesthesia, with proven effectiveness in various surgical interventions aimed at perioperative pain management. Evaluation of the effectiveness is based on pain assessment scales, intraoperative opioid use, and postoperative need for analgesics.

Detailed literature review on the history, techniques, benefits, and complications of caudal and general analgesia in pediatric patients. Development of a protocol for selecting patients suitable for these types of anesthetic technique. The study included patients in the age group of 0-7 years scheduled for elective and emergency surgical interventions suitable for both techniques. Statistical analysis of the obtained results.

The provided results for caudal anesthesia in the pediatric population from the Clinic of Pediatric Anesthesiology and Intensive Care, University Hospital "N.I. Pirogov," confirm the described results in the literature review on the topic - circulatory stability, high effectiveness of postoperative pain management, reduced need for analgesic drugs postoperatively compared to the data from the general anesthesia group patients.

Caudal anesthesia in pediatric patients is relatively safe, with minimal complication rates when properly executed within the indications for this type of anesthesia and preoperative analgesia - effective pain management and reduced psycho-emotional stress, improved quality of hospital stay, decreased opioid requirements, reduced consumption of analgesic drugs postoperatively. With qualified personnel and well-equipped facilities for both execution and management of potential complications, caudal anesthesia becomes the "gold standard" for the pediatric population.

Open humerus fractures occur in high energy major trauma. The incident rate in children is rare (<10%) predominantly between 9y and 15y of age. Pediatric analgesia, especially regional anesthesia and the use of peripheral nerve catheters is challenging but beneficial. Ultrasound guidance precises catheter placement, its effectiveness and sufficiency.

13y old boy, 62kg, suffers isolated open humerus fracture after car accident with metal platform hitting the car. He had 5/5cm bleeding lacerated wound in lateral humerus with preserved circulation, radial nerve contusion, restricted wrist and thumb extension. Initial treatment included wound debridement and external fixation of the fracture under general anesthesia. At the end of the procedure an US- guided intrascalene catheter was placed (4cm depth) followed up by bolus of Lidocaine 50mg+Ropivacaine 25mg and continuous infusion of Ropivacaine 0.1% V= 6ml/h. Patient needed no additional analgesia during the first postoperative day. He underwent second final surgery two days later, requiring catheter removal. Fracture was fixed with two intramedullary nails with no nerve palsy and no bleeding. Postoperative pain control included fractured doses of intravenous paracetamol and tramadol.

Patient remained calm and pain free during the first postoperative day with subjective pain score of 0-1 points (Visual Analogue Scale). Analgesia continued orally and intravenously after catheter removal and bone repairing.

Open proximal humerus fractures in children are uncommon and therefore challenging for treatment and pain control. External fixation is adequate initial treatment option but requires potent analgesia. US- guided intrascalene catheter s convenient and effective method for pain control.

The costoclavicular ultrasound-guided brachial plexus block (CBPB) is an increasingly used technique for upper limb surgery below the shoulder due to several advantages - linear anatomy, rapid onset of action, low failure rate and suitability for catheter placement. Despite its popularity, solid evidence on its efficacy and safety is still lacking. We intend to share our Centre’s experience performing CBPB and strengthen its role in Paediatric Anaesthesia.

We conducted a single-centre, retrospective, descriptive study and collected data from an anonymous regional anaesthesia database for a two-year period (January 2021 to December 2022). Data are expressed as percentages for categorical values and means for numerical ones.

A total of 225 ultrasound-guided, unilateral CBPB were performed: 3,6% as primary anaesthetic technique and the remaining 96,4% in combination with general anaesthesia. The CBPB was mainly used in arm and forearm surgery, and the surgical procedure for which it was used the most was osteosynthesis of supracondylar fractures (37,8%). Intravenous dexamethasone was used as an adjuvant in 86,6%. A perineural catheter was placed in 1,8% for continuous postoperative analgesia. Mean static/dynamic pain scores at 12h after surgery were 0 (median 0, SD ±1,7). A single case of a neurological complication (0,4%) was reported but it remains inconclusive if it was causally linked with the anaesthetic technique.

The CBPB is a feasible and safe alternative for upper arm surgery in the paediatric patient. Further prospects should also focus on intraoperative opioid consumption and the role of multimodal analgesia in postoperative pain control.

Regional anaesthesia techniques are effective and reliable instruments in Paediatrics. Given children’s naturally uncooperative behaviour, they are usually used in combination with deep sedation or general anaesthesia in order to obtain optimal surgical conditions. A greater, uncommon challenge emerges if the latter are contra-indicated and regional anaesthesia alone must be used. The following case displays the tools used to successfully anaesthetise an 11 year-old patient waiting for lung transplant using spinal anaesthesia only.

An 11 year-old, ASA IV patient was proposed for circumcision due to obstructive uropathy and uncontrollable pain caused by severe phimosis. The patient had a previous history of chronic lung disease with global respiratory failure, resulting in long-term supplemental oxygen and non-invasive ventilation, and is currently waiting for lung transplant. We decided to perform a saddle block taking into consideration the patient’s medical history.

The anaesthetic technique was carefully explained to the patient and his father, which both understood and consented. Diazepam (7 milligrams total) was administered as part of his fixed medication before entering the operative room for surgery. Saddle block was performed using intrathecal bupivacaine (7.5 milligrams total). Non-pharmacologic anxiolysis methods - music and digital technologies - were used throughout surgery. The patient was conscious and under spontaneous ventilation during the whole procedure, which ran uneventfully.

The case demonstrates regional anaesthesia does have a role as primary anaesthetic technique in Paediatrics and should still be considered for cases in which combined techniques are not suitable or even possible.

This systematic review strives to survey the various outcomes from a ketogenic diet in epileptic children. More specifically, to analyze evolving levels of parental stress from maintaining a lifestyle accompanied by anti-seizure medications. A balanced diet is vital to the wellbeing of children with epilepsy. Indeed, a ketogenic diet should potentially offer a positive impact on a child’s seizure control. Epilepsy type, duration, and seizure number are common variables.

In coalescence to a detailed literature search from the PubMed database, the NCBI National Library of Medicine database was also used. Data specific to parental stress as a result of the ketogenic diet for children with epilepsy. Variables such as type of epilepsy, length of diet, and amount of seizure control were explored.

Data retrieved from the above-mentioned literature depict the effect on parents sustaining a ketogenic diet for their children with epilepsy. Studies were performed over a period of 12 months. This study could be used to reflect on the effects a ketogenic diet has on seizure control in epileptic children. Moreover, to reflect on the parental stress as a result of this specific diet.

A ketogenic diet in children with epilepsy offers an impactful change to better control seizures. The connection of this study could be used to assess the relationship between a well balanced diet and seizure control in children with epilepsy. More research is needed to corroborate the functionality of a ketogenic diet in epileptic children.

Multifidus muscle is one of the transversospinales muscles, a group of muscles extending from cervical spine to sacrum. Previous reports of local anesthetic injections into nearby interfascial sacral planes show effective long-term analgesia for anal and urogenital procedures for both adult and pediatric patients. We aimed to evaluate the efficacy of multifidus plan block on postoperative analgesia and opioid consumption in rectal biopsy in children. Our primary aim was to evaluate postoperative pain scores, and our secondary aims were to evaluate the first postoperative analgesic requirement, total analgesic requirement in the first 24 hours and side effects.

A prospective, double-blind, randomized controlled study was conducted, including 40 patients aged between 0 and 2 years undergoing rectal biopsy.Group B patients will be placed in pron position and bilateral multifidus plan block will be performed with local anesthetic solution prepared with 1ml/kg bupivacaine at 0.25% concentration with ultrasound guidance using in-plane technique from cranial to caudal direction. Group C (control) regional block will not be performed.

Pain scores were significantly lower than control group all time points except 1, 18,24h. The time to first rescue analgesic was significantly longer and cumulative analgesic doses was lower in group B.

During the rectal biopsy, tissues are excised from external anal sphincter for pathological examination. As this procedure is quite painful and is often performed in neonates and infants, regional analgesia may be desirable to reduce the need for opiates. We believe multifidus plane block can be an effective and safe block for these patients.

The Erector Spinae Plane Block (ESPB) is a new regional anesthetic technique, and the global literature data on pediatric patients is still limited. The aim is to evaluate the analgesic power of the ESPB under ultrasound guidance when used in pediatric patients undergoing thoracic surgery. The effectiveness of the technique is based on opioid and non-opioid analgesic consumption within the first 24 hours postoperatively, as well as pain assessment scales

Pediatric patients aged 3-18 years old who underwent thoracic interventions between January 2022 and May 2023 at the Clinic of Pediatric Anesthesiology and Intensive Care. A 22G, 50mm needle was used for the technique, and the local anesthetic was Ropivacaine 0.25%, not exceeding a volume of 20ml unilaterally or separately for each side, while avoiding the maximum toxic dose of Ropivacaine of 2mg/kg

An overview of the literature data regarding the effectiveness of the ESPB is presented, along with the data obtained at the Clinic of Pediatric Anesthesiology which are compared to conventional venous analgesia. The possible complications are described based on both the literature data and observations at the Clinic

Reducing the pain,better comfort during hospital stay, and minimizing stress factors are of crucial importance, especially in the pediatric population. The advantages of regional anesthesia over venous analgesia, as well as the tendency to avoid central blocks when possible by using effective and sufficiently safe peripheral blocks, create favorable conditions for establishing the ESPB as a good, relatively easy technique for analgesia in the thoracic region, even in children.

Glossopharyngeal neuralgia (GN) prevalence in pediatrics is unknown(1). Common causes are schwannoma(2) and Chiari malformation(3). Pharmacotherapy is the cornerstone with a poor efficacy around %(4). Invasive treatment has been described(5) ,but there is not date about the use of pulsed radiofrequency (PRF) on pediatric patients with GN, although in adults there are some(6). We present a successful case of a child with primary GN treated with PRF.

A 9-year-old female with a history of one year of GN unresponsive to medical treatment was referred to our pain clinic. She had a glossopharyngeal nerve block with complete pain relief for 2 weeks. Because the short-pain-relief a PRF was scheduled. After informed consent, using GA with aseptic conditions using ultrasound with a linear-high- frequency-transducer, the styloid process and the carotid artery were identified. An in-plane approach toward the posterior aspect of the styloid using hydrodissection with saline with a further Contrast injection verifying with fluoroscopy the final target. Because she was under GA no sensitive stimulus was delivered. PRF was performed with 2 cycles of 42C/4minutes/85volts. Then 3ml of bupivacaine-0.5% without epinephrine plus 2 milligrams of dexamethasone were administered (figures 1,2)

There were not complications recorded during or after the procedure. The patient experienced a pain relief of 60% during the first week, and a continues benefit of 85% during a 6-month-follow-up.

PRF may represent an interesting therapeutic alternative and minimally invasive option in pediatric population. Further studies are needed to stablish the role of PRF in craniofacial pain in pediatrics.

Ketodex is effective in achieving sedation and has a favorable safety profile in pediatric patients undergoing MRI and invasive procedures, while producing minimal adverse effects.

A 6-year-old female patient, ASA III status, weighing 21 kg, with a history of type I mucopolysaccharidosis was proposed for bilateral median nerve release with tourniquet due to carpal tunnel syndrome. Preoperative evaluation showed indicators of a potentially difficult airway (Mallampati class IV, retrognathia, limited neck extension, macroglossia). The patient was proposed for locoregional anesthesia with sedation and standard ASA+BIS monitoring. A loading dose of ketamine+dexmedetomidine ("ketodex") was administered, according to the hospital protocol, consisting of 1 mg/kg of ketamine and 1 µg/kg of dexmedetomidine over 10 minutes. The patient maintained SpO2>98% with 2 L/min of nasal cannula, hemodynamic stability, with BIS 70-80 on EEG. Bilateral costoclavicular blockade was performed under ultrasound guidance with 5 mL of 0.2% ropivacaine + 5 mL of 1.5% mepivacaine. Sedation was maintained with a titrated dose of ketodex according to BIS (maximum dose 1 µg/kg/h). Administration of 300 mg of paracetamol and 10 mg of ketorolac at the end.

The procedure was completed without complications. The patient was transferred to the post-anesthesia care unit without pain complaints, hemodynamically stable, and with SpO2 ~99% with 1 L/min of nasal cannula.

This case underscores the importance of tailored anesthetic management in pediatric patients with comorbidities and difficult airway. Effective implementation of clinical guidance protocols and in-depth knowledge of drug pharmacology were crucial for the successful anesthetic management in this case report.