H17

BEST FREE PAPER 1 – RA
BEST FREE PAPER 1 – RA

BEST FREE PAPER 1 – RA
BEST FREE PAPER 1 – RA

Chairperson: Dan Sebastian DIRZU (consultant) (Chairperson, Cluj-Napoca, Romania)

Jurys: Steve COPPENS (Head of Clinic) (Jury, Leuven, Belgium), Wojciech GOLA (Consultant) (Jury, Kielce, Poland), Julien RAFT (anesthésiste réanimateur) (Jury, Nancy, France), Thomas WIESMANN (Head of the Dept.) (Jury, Schwäbisch Hall, Germany)

15:30 - 15:41 #33636 - OP001 PROSPECT Guideline for Haemorrhoid Surgery: A Systematic Review and Procedure‐specific Postoperative Pain Management Recommendations.

OP001 PROSPECT Guideline for Haemorrhoid Surgery: A Systematic Review and Procedure‐specific Postoperative Pain Management Recommendations.

Haemorrhoidectomy is associated with moderate-to-severe postoperative pain. The aim of this systematic review was to assess the available literature and update previous PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) recommendations for optimal pain management after haemorrhoidectomy.

A systematic review utilizing PROSPECT methodology was undertaken. Randomized controlled trials published in the English language from January 1, 2016 to February 2, 2022 assessing postoperative pain using analgesic, anaesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Database.

Of the 371 RCTs identified, 84 RCTs and 19 systematic reviews, meta-analyses met our inclusion criteria (total: 103 publications). Interventions that improved postoperative pain relief included: paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, systemic steroids, pudendal nerve block, topical metronidazole, topical diltiazem, topical sucralfate or topical glyceryl trinitrate, and intramuscular injection of botulinum toxin.

This review has updated the previous recommendations written by our group. Important changes reside in abandoning oral metronidazole and recommending topical metronidazole, topical diltiazem, topical sucralfate, topical glyceryl trinitrate. Botulinum toxin can also be administered. Contemporary publications confirm the analgesic effect of bilateral pudendal nerve block but invalidate recommendations on perianal infiltration. The choice of the surgery is mostly left to the discretion of the surgeon based on his experience, expertise, type of haemorrhoids, and risk of relapse. That said, excisional surgery is more painful than other procedures.

Alexis BIKFALVI (Lausanne, Switzerland), Charlotte FAES, Stephan M. FREYS, Girish P. JOSHI, Marc VAN DE VELDE, Eric ALBRECHT

15:41 - 15:52 #34447 - OP002 PAK4 inhibitor reduces remifentanil-induced postoperative hyperalgesia in rat.

OP002 PAK4 inhibitor reduces remifentanil-induced postoperative hyperalgesia in rat.

The purpose of this study was to evaluate the relationship between remifentanil-induced hyperalgesia(RIH) and p21 activated kinase4(PAK4) in the spinal dorsal horn of rats with incisional pain.

Sprague-Dawley rats weighing 280-300g aged 9-11 weeks were divided into four groups (n = 12 each): control group(C), incisional pain group(I), incisional pain+remifentanil group(IR), incisional pain+remifentanil+PAK4 inhibitor group(IRP). Groups I and C received intravenous saline, while Group IR and IRP received intravenous remifentanil at dose of 1.2 μg·kg⁃1·min⁃1 for 90 minutes. PAK4 inhibitor PF3758309 10 nmol was intrathecally injected 30 minutes before surgery and once daily for five days after incision in group IRP, while the same intrathecal injection with DMSO in the other groups. The paw mechanical withdrawal threshold (PMWT) was measured respectively at 30 min before surgery and at 2 hours, 1 to 5 days after surgery. NLRP3 in spinal dorsal horn was detected by Western Blot.

PMWT decreased at 2 hours after surgery in the incisional side. PMWT of healthy foot only decreased in group I and IR at 2 hours after surgery. Compared with group IR, PMWT increased in group IRP at 3 days after surgery in incisional side, while at 2 hours in healthy side. This study indicates that PF3758309 could cut off the formation of RIH since 2 hours after surgery by modulating NLRP3 inflammasome activation conducted by PAK4 in spinal dorsal horn.

PAK4 inhibitor could be effective to decrease the development and maintenance of RIH and increase pain threshold in rats.

Zhang TIANYAO (Chengdu, China), Dong SHUHUA, Cui CHANG, Zhang YONGJUN, Zeng LING

15:52 - 16:03 #34489 - OP003 IPACK (Infiltration between the Popliteal Artery and the Capsule of the Knee) and Adductor Canal Block (ACB) versus Periarticular Injection (PAI) Enhances Postoperative Pain Control in Anterior cruciate ligament (ACL) repair: A Randomized Controlled Tria.

OP003 IPACK (Infiltration between the Popliteal Artery and the Capsule of the Knee) and Adductor Canal Block (ACB) versus Periarticular Injection (PAI) Enhances Postoperative Pain Control in Anterior cruciate ligament (ACL) repair: A Randomized Controlled Tria.

Periarticular injections (PAIs) are becoming a component of multimodal joint pathways. Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the knee (IPACK) and the adductor canal block (ACB), may augment PAI in multimodal analgesic pathways for knee surgery, but supporting literature remains rare. We hypothesized that ACB and IPACK would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone.

This triple-blinded randomized controlled trial included 50 patients undergoing ACL repair. Patients either received (1) a PAI (control group, n = 26) or (2) an iPACK with an ACB (intervention group, n = 24). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption.

The intervention group reported significantly lower NRS pain scores on ambulation than the control group on POD 1 ( [95% confidence interval], -3.3 [-4.0 to -2.7]; P < .001). In addition, NRS pain scores on ambulation on POD 0 (-3.5 [-4.3 to -2.7]; P < .001) and POD 2 (-1.0 [-1.9 to -0.1]; P = .033) were significantly lower. Patients in the intervention group were more satisfied, had less opioid consumption (P = .005, post anesthesia care unit, P = .028, POD 0), less intravenous opioids (P < .001), and reduced need for intravenous patient-controlled analgesia (P = .037).

The addition of iPACK and ACB significantly improves analgesia and reduces opioid consumption after ACL repair compared to PAI alone.

Aboud ALJABARI (Riyadh, Saudi Arabia)

16:03 - 16:14 #35665 - OP004 High- versus low- dose dexamethasone (DEX) for postoperative analgesia after caesarean section (CS): A randomized, double-blind, two-center study.

OP004 High- versus low- dose dexamethasone (DEX) for postoperative analgesia after caesarean section (CS): A randomized, double-blind, two-center study.

Effective analgesia after CS is essential to enhance recovery. Recent PROSPECT guidelines highlighted the importance of multimodal analgesia including paracetamol, NSAIDs, regional anesthesia and IV Dexamethasone(1). Usually, doses of Dexamethasone are <10mg. In orthopedic surgery higher doses of Dexamethasone (>0.2mg/kg) seem to generate analgesic superiority(2,3). This randomized, double-blind study aimed to compare HIGH- versus LOW-dose Dexamethasone for post-CS analgesia.

Following ethical approval and informed consent, 210 patients undergoing CS were randomized to 5mg or 2x25mg of IV-Dexamethasone. Multimodal analgesia was given in both groups including paracetamol, NSAIDs, wound infiltration and bilateral ilio-inguinal nerve block. Opioids were given as rescue. In the LOW-group 5mg IV-Dexamethasone was given after delivery. In the HIGH-group 25mg IV-Dexamethasone was given after delivery and 24hours later. Primary endpoint was the cumulated NRS-pain scores at movement 4-48 hours after CS quantified as area under the curve (AUC). Secondary endpoints included pain scores at rest, patient satisfaction, rescue analgesics, side-effects and functional recovery.

In the HIGH-group the hourly AUC pain score at movement was significantly reduced by 15% from 3.11±1.14 to 2.65±1.25 (p=0.0011), and pain scores at rest and highest pain scores were lower. Less patients required rescue opioids (75% vs 58%, p=0.011), morphine consumption was reduced (9.1 to 5.2mg, p=0.0003) and functional recovery improved. Glycemia and wound healing were normal in both groups.

Compared to a single 5mg dose of Dexamethasone, 2 x 25mg Dexamethasone added to multimodal analgesia provided superior analgesia with lower opioid consumption without an increase in side-effects. References: 1.Roofthooftetal.Anaesthesia2021;76,665-680. 2.Lunnetal.BritJAnaesth2011;106,230–238. 3.VandeVeldeMetal.EurJAnaesthesiol2023;40,151–152.

Charlotte DE LOECKER (Leuven, Belgium), Eva ROOFTHOOFT, Cynthia A WONG, Henrik KEHLET, Steffen REX, Marc VAN DE VELDE

16:14 - 16:25 #35751 - OP005 Comparison of efficacy of ultrasound guided serratus anterior plane block versus erector spinae plane block for postoperative analgesia after modified radical mastectomy-a randomized controlled trial.

OP005 Comparison of efficacy of ultrasound guided serratus anterior plane block versus erector spinae plane block for postoperative analgesia after modified radical mastectomy-a randomized controlled trial.

Several interfascial plane blocks have been described in patients undergoing modified radical mastectomy (MRM). However, the most efficacious technique is not known. So, we conducted this study to evaluate the analgesic efficacy of ultrasound guided serratus anterior plane (SAP) block and erector spinae plane (ESP) block in patients undergoing MRM.

80 female patients (18-70 years) undergoing MRM were randomized to two groups of 40 each and given ultrasound guided SAP block or ESP block with 0.4ml/kg of 0.375% ropivacaine in this prospective double-blind control trial. The groups were compared for the time to first dose of rescue analgesic, requirement of rescue analgesics and patient satisfaction score.

The time to first rescue analgesia was significantly prolonged in SAP group as compared to ESP group (p=0.03). The probability of a patient being pain-free (NRS<3) was significantly higher in SAP group than ESP group. Postoperative pain scores at rest at 0 minute was significantly lower in SAP group as compared to ESP group. The intraoperative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable between the two groups. The number of patients requiring rescue doses of fentanyl intraoperatively and rescue analgesics postoperatively were similar in both the groups. The mean patient satisfaction score was also comparable in both groups.

Ultrasound guided SAP block significantly prolonged the time to first rescue analgesia and a small trend toward lower requirement of rescue analgesics and better patient satisfaction as compared to ESP block in patients undergoing MRM.

Vinod KUMAR, Deepti AHUJA, Nishkarsh GUPTA (Delhi, India), Sushma BHATNAGAR, Seema MISHRA, Sachidanand Jee BHARATI, Rakesh GARG

16:25 - 16:36 #35986 - OP006 Effect on sacral spread of local anesthetic with 27-G spinal needle Dural Puncture Epidural Analgesia compared to Epidural Analgesia during labor: a randomised, controlled trial.

OP006 Effect on sacral spread of local anesthetic with 27-G spinal needle Dural Puncture Epidural Analgesia compared to Epidural Analgesia during labor: a randomised, controlled trial.

The Dural Puncture Epidural (DPE) seems to provide better sacral labor analgesia than the conventional Epidural (EPL) technique when performed with 25 and 26-G spinal needles. This double-blinded randomized controlled trial aims to investigate whether a 27-G needle DPE results in faster bilateral sacral blockade compared to EPL.

Following ethics approval and written consent, 108 nulliparous women were included. 54 patients received a conventional EPL, while the DPE group (n=54) received a needle-through-needle dural puncture technique using a 27-G Whitacre needle. In both groups analgesia was initiated epidurally with 15 mL of ropivacaine 0.1% and sufentanil 0.5 mcg∙ mL–1 and maintained with 10 ml bolus of the same mixture provided hourly through a Programmed Intermittent Epidural Bolus infusion. Bilateral sacral blockade was tested at the S2 dermatomes using a pin-prick examination 10 minutes after analgesia completion, then at pre-defined intervals until delivery.

Time to bilateral sacral blockade was significantly different in the two groups (hazard ratio 0.30, 95% confidence interval [CI] 0.19 to 0.48, P<0.001). One hour after analgesia initiation 94% DPE patients achieved bilateral sacral blockade compared to 63% of the EPL group (P <0.001), with greater results at 10 minutes (risk ratio [RR] 3.00, 95% CI 1.69 to 5.29; P<0.001) and at 20 minutes (RR 2.38, 95% CI 1.35 to 4.21; P=0.001).

Within 1 hour after initiation of neuraxial analgesia, the DPE technique using a 27-G Whitacre spinal needle provides an improved S2 dermatomes coverage compared to EPL.

Nicoletta FILETICI (Rome, Italy), Luciano FRASSANITO, Marc VAN DE VELDE, Lawrence TSEN, Bruno Antonio ZANFINI, Stefano CATARCI, Mariano CIANCIA, Gaetano DRAISCI

16:36 - 16:47 #36097 - OP007 Analgesic efficacy of selective tibial nerve block versus partial local infiltration analgesia for posterior pain after total knee arthroplasty: a randomised, controlled, triple-blinded trial.

OP007 Analgesic efficacy of selective tibial nerve block versus partial local infiltration analgesia for posterior pain after total knee arthroplasty: a randomised, controlled, triple-blinded trial.

The adductor canal block relieves pain on the anterior aspect of the knee after arthroplasty. Pain on the posterior aspect might be treated either by partial local infiltration analgesia of the posterior capsule or by a tibial nerve block This randomised, controlled, triple-blinded trial tested the hypothesis that a tibial nerve block would provide superior analgesia than a posterior capsule infiltration in patients scheduled for total knee arthroplasty under spinal anaesthesia with an adductor canal block.

Sixty patients were randomised to receive either an infiltration of the posterior capsule by the surgeon with ropivacaine 0.2%, 25mL or a tibial nerve block with ropivacaine 0.5%, 10mL. Sham injections were performed to guarantee proper blinding.

The primary outcome was intravenous morphine consumption at 24h. Secondary outcomes included intravenous morphine consumption, pain scores at rest and on movement, and different functional outcomes, measured at up to 48h. When necessary, longitudinal analyses were performed with a mixed-effects linear model. The median (interquartile range) of cumulative intravenous morphine consumption at 24h was 12mg (4–16) and 8mg (2–14) in patients having respectively the infiltration or the tibial nerve block (p=0.20). Our longitudinal model showed a significant interaction between group and time in favour of the tibial nerve block (p=0.015).

No significant differences were present between groups in the other above-mentioned secondary outcomes. In conclusion, a tibial nerve block does not provide superior analgesia when compared to infiltration. However, a tibial nerve block might be associated with a slower increase in morphine consumption along time.

Frédérique PAULOU (Lausanne, Switzerland), Eric ALBRECHT, Erin GONVERS, Julien WEGRZYN, Maya KAEGI

16:47 - 16:58 #36289 - OP008 Evaluation of the ‘sip til send’ regimen before caesarean delivery using bedside gastric ultrasound: a paired pragmatic cohort study.

OP008 Evaluation of the ‘sip til send’ regimen before caesarean delivery using bedside gastric ultrasound: a paired pragmatic cohort study.

Preoperative fasting partially mitigates against pulmonary aspiration following anaesthesia. International guidelines specify fasting periods of 6-8 hours for food and 2 hours for clear fluid prior to all surgeries, including caesarean delivery (CD). Prolonged fasting has deleterious effects and contemporary anaesthesia practice has evolved towards reduced fasting times for CD via liberal drinking regimes, including ‘Sip Til Send’. Our primary aim was to compare standard fasting against ‘Sip Til Send’ using gastric ultrasound in a paired cohort non-inferiority study using a pragmatic study design.

Fully fasted parturients due to undergo elective CD under neuraxial anaesthesia were recruited and commenced on ‘Sip Til Send’ fasting before surgery. Qualitative and quantitative gastric ultrasounds were performed via a standardised approach following recruitment and prior to induction of anaesthesia.

69 patients were assessed for eligibility and 55 recruited. Analysis was incomplete on two scans due to artefact impeding interpretability. The mean ‘Sip Til Send’ fasting time was 192.6 ± 108.7 minutes, with participants drinking a mean of 113.7 ± 70.4 ml.hr-1. Notably, seven participants drank more than the suggested 170 ml.hr-1. There were no statistical differences between groups (Table 1). Estimation of gastric content volume yielded 3 and 5 parturients with gastric contents greater than 1.5ml.kg-1 in the fully fasted and ‘Sip Til Send’ fasted states, respectively.

‘Sip Til Send’ fasting with water was non-inferior to a standard fasting protocol as tested in a pragmatic hospital setting. Therefore, it should be considered for elective CD and may prove beneficial in other areas of anaesthesia.

Shane KELLY (Dublin, Ireland), Jesse CONNORS, Colleen HARNETT, Terry TAN, Ryan HOWLE

16:58 - 17:09 #36294 - OP009 EXTRAFASCIAL INJECTION VERSUS INTRAFASCIAL INJECTION FOR INTERSCALENE BRACHIAL PLEXUS BLOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS.

OP009 EXTRAFASCIAL INJECTION VERSUS INTRAFASCIAL INJECTION FOR INTERSCALENE BRACHIAL PLEXUS BLOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Ultrasound-guided Interscalene brachial plexus block is typically administered to patients undergoing surgery in the upper limbs. Recently, extrafascial injection has been introduced; however, its efficacy and safety remain debatable. This systematic review meta-analysis (PROSPERO: CRD42023426498) sought to compare extrafascial and intrafascial injections.

We systematically searched six electronic databases for randomised clinical trials comparing extrafascial and intrafascial injections for interscalene brachial plexus block. A random-effects model calculated risk ratio or mean differences (MD) with a 95% confidence interval (CI). The Cochrane Risk of Bias tool was used to assess the risk of bias.

Six studies, a total of 485 patients, met our criteria. The risk of bias in four studies was low, with some concerns in two. The incidence of hemidiaphragmatic paresis was less in the extrafascial injection: [RR 3.01; 95% CI (2.13, 4.25); P < 0.00001]. There was a significantly higher incidence of complications in intrafascial compared to the extrafascial group for paraesthesia and hoarseness; RR 7.39; 95% CI (1.88, 29.07); P = 0.004] and [RR 3.88; 95% CI (0.99, 15.19); P = 0.05], respectively. Onsets of motor and sensory block were rapid in the intrafascial group: [MD -5.48; 95% CI (-8.85, -2.11); P = 0.001] and [MD -5.01; 95% CI (-8.49, -1.54); P = 0.005], respectively. The duration of sensory block was not significantly different between both groups: [MD 17.92; 95% CI (-38.15, 74.00); P = 0.53].

Extrafascial injection effectively reduces block-related complications such as hemidiaphragmatic paresis and is associated with preserving respiratory parameters such as forced vital Capacity.

Eslam AFIFI, Mazen Negmeldin Aly YASSIN, Mohamed EL-SAMAHY, Yusra ARAFEH, Mahfouz SHARAPI (Dublin, Ireland), Jubil THOMAS