Despite advancements in drug and surgical treatments, chronic back pain following failed back surgery remains a significant challenge. Some patients endure persistent pain unresponsive to conventional therapies, resulting in medication tolerance and surgical risks. Spinal cord stimulation (SCS) has emerged as a non-pharmacological innovative option to regulate pain signals in this specific population.

We present a case series of 20 patients, with intractable chronic pain, after extensive treatments, including physiotherapy and multiple surgeries. They experienced severe pain, significantly impacting their quality of life. Duration of treatment application was documented, its effect on pain intensity was measured by the VAS scale (0-10), and the DN4 questionnaire. To assess its impact on quality of life, we administered the SF12 questionnaire before the intervention and six months later, alongside any alterations in their medication regimen.

The results demonstrated a >45% in VAS scale and 50% reduction in DN4 questionnaire respectively. Patients reported a notable improvement in their quality of life, marked by return to simple everyday activities. The implementation of SCS resulted in a reduction in systemic drug therapy. However, one SCS had to be removed due to infection.

SCS effectively treats drug-resistant chronic pain, improving patients' quality of life in cases of failed back surgery syndrome. This underscores SCS's potential in challenging scenarios and advocates for its integration into specialized centers of excellence. SCS significantly reduces the burden of chronic pain, offering a safe alternative to traditional methods. Embracing SCS represents a crucial advancement in optimizing patient outcomes.

This study aimed to compare the efficacy of single and double injections of ultrasound-guided superficial parasternal intercostal plane blocks (S-PIPB). We hypothesized that double injections would yield superior success rates in achieving sensory blockade compared to the single injection technique.

Seventy cardiac patients undergoing median sternotomy were randomly assigned to receive single or double injections of S-PIPB bilaterally. Each patient received 40 mL of 0.25% bupivacaine with epinephrine 5 μg/mL and dexamethasone 10 mg. Twenty mL/side was injected at the 3rd intercostal level in single-injection group, while 10 mL/injection was administered at the 2nd and 4th intercostal spaces in double-injection group. The primary outcome was successful S-PIPB, defined as sensory loss in the T2-T6 dermatomes at 30 minutes post-block. Secondary outcomes included block-related complications, intraoperative hemodynamics during sternotomy, fentanyl consumption, postoperative pain, and recovery quality.

Double injections of S-PIPB achieved greater success rates on both sides of the chest walls (81% vs 51%, P<0.001) and increased the percentage of blockade in dermatomes T1 (83% vs 59%, P<0.003), T7 (67% vs 46%, P<0.017), and T8 (61% vs 39%, P=0.001) compared to single injection. One hematoma occurred in the double-injection group. Intraoperative hemodynamics, postoperative pain, and recovery outcomes were comparable between the two groups.

When compared to a single injection, double injections of S-PIPB provided extended coverage of the T2-T6 dermatomes, which are crucial for median sternotomy. However, no differences were observed in intraoperative hemodynamic effects or postoperative pain control after cardiac surgery.

Neurolysis with ultrasound-guided Stellate ganglion block (SGB) offers a minimally invasive and targeted approach for managing the symptoms of chronic Raynaud phenomenon (RP) such as digital ischemia and pain.

We were referred a 39 year old female patient with Systemic Sclerosis and developed RP since 8 months, who had necrosis of the first, second and third digits of the right hand with pulsating pins and needles sensation. The pain was especially intense during the night, and did not subside after systemic multimodal analgesia. We performed neurolysis ultrasound-guided SGB. With 1 ml of 1% lidocaine on the surface of longus colli muscle at the level C6, patient confirmed lesser pain sensation. Then we continued to deposit 0.5 ml of 2% lidocaine, 2 ml of 96% alcohol, 0.5 ml of 0.5% bupivacaine and dexametasone 2.5mg on the surface of longus colli muscle at the level C6 and at the level of C7.

Significant pain relief accompanied with transient Horner Syndrome on the right side showed within minutes after procedures completion. During the first week patient showed significant pain relief, morphine was tapered off and stopped in first week. After seven days post SGB procedure, patient started to feel the pain again especially at night, although the intensity was still manageable with clonidine and diclofenac.

The positive outcome of the procedure with significant pain relief and reduced reliance on systemic analgesia, suggests that SGB can be a valuable intervention for chronic intractable RP

Adductor canal block (ACB) is an effective analgesic technique for lower limb surgeries. Anatomic studies on injectate spread yield mixed results. Here, we assess dye spread at three distinct adductor canal locations.

An observational cadaveric study was conducted. Twelve lower limbs from fresh unembalmed cadavers were studied. An ultrasound-guided adductor canal block with 20 ml of methylene blue was performed in each limb in one of three locations that was defined according to the location of femoral artery (FA): Medial (proximal adductor canal), inferior (mid-adductor canal), and lateral (distal adductor canal) to the mid-point of the sartorius muscle (SM). Nine limbs (three of each injection location) were dissected to asses spread location. The 3 other specimens were sectioned in coronal slices for further anatomical examination. We hypothesized that proximal (femoral triangle, femoral nerve) and distal (popliteal fosa) spread would differ according to the injection location.

Regardless of injection location, staining was observed in adductor canal in all specimens. In the proximal injection, 3 specimens (75%) had staining of the femoral nerve, without distal spread. In the mid-location, no proximal nor distal spread was noted. In the distal location, in 1 specimen (25%) spread reached the popliteal fossa, while in 2 cases (50%) it reached the adductor hiatus without staining the popliteal fossa. No femoral triangle spread was observed in the distal location.

An ACB performed in the mid-location (fermoral artery inferior to the sartorius muscle) does not result in proximal nor distal spread.

The intensive care unit (ICU) patient outcomes maybe influenced by the time of admission. We hypothesized that patients admitted to the ICU at afterhour would have more risk of death.

We defined the afterhour as the period of time between 22:00 and 06:59 h. A retrospective study was conducted from January 2018 to June 2018 in ICU. The primary outcomes was ICU mortality within 30h, 30days and 7 days following admission and ICU length of stay. Other variables were included: age, sex, comorbidities, source of referral, reason for admission.

Of 150 admissions, 34% occurred afterhour. Most afterhour admissions were men and were referred from emergency department (67.9%). They had lower APACHII and IGSII scores. More mortality was observed for those admitted at workhour (but was not significant). Analysis showed no association between afterhour admission and hospital length of stay, length of mechanical ventilation and death within 24h, althought it was higher.

Patients admitted afterhours were not significantly different from patients admitted at workhour. Incidence of men was more important and this can be explained by the frequency of road accidents at night and they were most commonly referred from the emergency department. We found no effect of afterhours admission on ICU mortality. It was even less than the mortality of patients admitted at workhour but death within 24 h was higher. This reflect probably a better initial management of admission at workhour. Afterhour ICU admission is not associated with higher mortality risk.

We compared the superiority of two infraclavicular approaches, costoclavicular (CC) and lateral sagittal (LS), especially their sensorimotor effects and hemidiaphragmatic paralysis rates.

Informed consent was obtained from 91 patients aged 18-80 years, ASA I-III, undergoing elective forearm and hand surgery. They were randomly assigned to 2 groups. Diaphragmatic movements were measured by USG in M-mode during deep and normal breathing. For both approaches, 30 mL of bupivacaine was injected with USG and nerve stimulator. Musculocutaneous, median, ulnar and radial nerve sensorimotor losses were checked every 5 minutes for 30 minutes. Diaphragmatic excursion was measured again 30 minutes after the block. The tourniquet area was checked and painless patients were not infiltrated, whereas others were infiltrated.

The onset time of sensory and motor block of the musculocutaneous and median nerves, motor block of the radial nerve and sensory block of the ulnar nerve and the number of patients with complete block at the end of 30 minutes were not different in either groups. During normal breathing, partial paralysis was observed in 10 CC and 11 LS patients, no complete paralysis. During deep breathing, partial paralysis was observed in 6 CC and 5 LS patients, no complete paralysis. Diaphragm excursion differences measured at baseline and 30 minutes after block were not significantly different in either group. Tourniquet infiltration was required significantly less in the CC than LS group.

In conclusion, we think that both approaches can be used safely especially in patients with respiratory system diseases, but more studies are needed.

Postoperative-pain management in shoulder arthroscopy surgeries, traditionally involves an interscalene brachial-plexus block. Since the shoulder receives innervation through the suprascapular, axillary, lateral pectoral and subscapularis nerves, a more distal block was conceptualized to provide an infra-omohyoid suprascapular nerve and subscapularis plane block, which we termed as “shoulder block”. The primary outcome variable was incidence of rebound pain(transient acute-pain post-block resolution); secondary outcomes included NRS at various time points, time to rescue-analgesic (TTRA-tramadol), patient satisfaction, sleep disturbance and incidence of diaphragmatic-paresis(DP).

20 ASA-I and II patients undergoing arthroscopic rotator cuff repair, were given an ultrasound-guided (Fijifilm sonosite edge 2) shoulder block(total 20ml 0.25% bupivacaine). General anaesthesia was induced prior to blocks with standard protocol. Prior to skin closure, all patients received intravenous diclofenac(75mg) and 1gm-PCM(8hourly thereafter). Postoperatively, time to rebound pain (NRS value ≥7 after block resolution was taken as criterion for evaluating rebound pain), NRS at various time points, total opioid consumption, sleep disturbance and patient satisfaction-scores were noted. Diaphragmatic function(using USG) was noted at 2 hours postoperatively in recovery.

In 1/20 patient with the NRS>7 (RPS) ,tramadol(50 mg around 12hours postop) was required. In 5/20 patients with NRS> 4, tramadol(one dose) was needed[figure-1].The TTRA was a mean of 603mins[bell-curve-figure 2]. Sleep disturbance (3/20), patient satisfaction score (>90%)and incidence of mild DP (3/20)were other observed variables .

Our study demonstrates significant reduction in rebound pain (NRS>7) and opioid consumption after “shoulder block” in shoulder arthroscopic surgeries. However, a further comparative trial is mandatory with the gold standard-interscalene block.

Formalised ultrasound guided regional anaesthesia (USGRA) training is resource intensive and often difficult to access. Assistive artificial intelligence (AI) is an emerging technology with potential to enhance training and provision of USGRA. We aim to evaluate if ScanNAV(TM) (Intelligent Ultrasound Limited) can enhance USGRA image acquisition of a ‘Plan-A Block’ for the non-expert in the absence of formalised training.

18 anaesthetists performed sonoanatomy on live models for two pre-selected Plan-A blocks, one with and one without prior formal training. ScanNAV(TM) was used in the latter alongside ScanNAV(TM) tutorial videos and RA-UK infographic material for reference. 2 expert assessors made objective assessments for each using a protocolised data collection tool.

15/18 (83.3%) participants successfully acquired appropriate ultrasound images for a Plan-A Block using ScanNAV(TM) and reference materials with no formal prior training. Sonoanatomy scans were performed faster on average in block procedures that had received prior formal USGRA training. The adductor canal block had an average procedure time of 23.52seconds vs 179.17seconds (t-test value 2.74; p-value 0.0168). Where formal training had taken place, participants scored higher in identifying key structures (ASRA-ESRA Delphi consensus) across all Plan-A blocks, as well as accuracy grade of image acquisition and needle path safety.

Assistive AI, e.g. ScanNAV(TM) may facilitate image acquisition and identification of key sonoanatomical stuctures in the absence of formalised training. This technology should be used as an adjunct, not a replacement, for formalised training as objective assessment in speed, accuracy and safety were seen to be superior in this subgroup.

Performance of nerve block using ultrasound has improved success, reduced errors, and minimized complications. Skills related to the use of ultrasound are difficult to learn, however simulation has been proposed [Gallagher et al] as it allows trainees to rehearse procedural skills safely. To be effective, simulation must be integrated into a validated curriculum.

We undertook a series of studies in Cork University Hospital, Ireland to develop, validate and implement training programme relevant to performance of ultrasound guided axillary brachial plexus block (UGABPB). A panel of experts deconstructed the task of performing UGABPB to identify metrics and errors [Ahmed et al]. Thereafter, face and content validity were verified using a modified Delphi method. Metrics and errors were subjected to a validation process [Ahmed et al]. Video recording experts and novices performing the block on live patients were captured and assessed by two independent observers using validated metrics. The inter-rater reliability between the two observers was measured. Trainees were randomly allocated to either metric-based training group or traditional training group.

54 metrics and 32 errors were identified and unambiguously defined. Compared to novices, experts scored more steps and committed less errors when assessed using validated metrics. Construct validity was verified with an inter-rater reliability of more than 0.8. Trainees randomly allocated to metric based curriculum outperform their traditionally trained counterparts when they were assessed performing UGABPB in simulated platforms.

Metric based simulation training improved novice performance of UGABPB in simulation platform. Future studies should examine the impact on patients’ clinical outcomes.

High-concentration (8%) capsaicin patches have shown promise in treating chronic neuropathic pain. Their approved use is limited to neuropathy associated with HIV infection, painful diabetic peripheral neuropathy, or postherpetic neuralgia, and to areas distant from mucous membranes.

We selected two patients (A and B). Patient A had neuropathic pain in the upper lip secondary to radiotherapy. The painful area was marked and the patch cut to size, ensuring mucous membranes were protected. Patient B had neuropathic pain in the right ilioinguinal and genitofemoral area with a painful scar from right inguinal eventroplasty, refractory to botulinum toxin and pulsed radiofrequency treatment. Both patients received three treatment sessions 5 months apart from each other. The patch was applied for 20 minutes to the upper lip and 60 minutes to the inguinal area. The response was measured using the Visual Analog Scale (VAS).

Patient A: Pre-treatment VAS was 9. After the first application, there was no improvement. During the second application, the patient experienced burning and itching. After the third application, VAS improved to 6. Patient B: Pre-treatment VAS was 7. From the first application, classic adverse symptoms of burning and itching were noticed, followed by improvement days after. After the third application, the VAS was 4.

Qutenza appears effective for neuropathic pain from conditions not included in the technical specifications and in unusual body areas. The treatment response appears to improve with repeated applications. Qutenza shows promise as an alternative for chronic neuropathic pain, warranting further studies to expand its indications.

Postoperative pain management in minimally invasive nephrectomy remains a critical aspect of patient care. This study explores the potential of low dose intrathecal preservative free morphine as a promising analgesic modality for enhancing postoperative pain control while minimizing systemic opioid requirements and associated side effects, thereby improving patient outcomes.

Patients scheduled for elective laparoscopic or robotic-assisted nephrectomy were included in this single-center, double-blind, prospective randomized placebo-controlled trial. Preoperatively patients were randomly assigned using computer generated block randomisation sequence to receive intrathecal morphine 200 mcg with 1 ml 0.5% Bupivacaine hydrochloride in dextrose injection (Group-M) or a sham procedure (Group-C). All patients received standard intraoperative multimodal analgesia and postoperative patient-controlled analgesia with intravenous morphine. Primary outcome was 24-hour intravenous morphine consumption. Secondary outcomes were intraoperative and 48-hour postoperative fentanyl requirement, static pain scores, dynamic pain on first ambulation and on coughing, postoperative complications, postoperative length of hospital stay and patient satisfaction score. P-value < 0.05 was considered as significant.

A total of sixty-two patients were recruited. The intravenous morphine consumption 24 hours after surgery was significantly lower in Group-M (16.5 ± 12.3 mg) versus Group-C (27.2 ± 12.1 mg), p=0.001. There were significant differences in static pain scores up to first 12 hours and dynamic pain on first ambulation and coughing. Intraoperative and 48-hour postoperative rescue fentanyl requirements were significantly lower in Group-M, p<0.05 (Table 1).

Intrathecal morphine significantly reduces postoperative morphine requirement and postoperative pain scores.

We aim to investigate the safety and feasibility of remimazolam-based monitored anesthesia care (MAC) in patients undergoing transurethral resection of bladder tumor (TURBT) guided by analgesia nociception index (ANI) monitoring, while comparing the net anesthesia time (anesthesia time excluding procedure time) between MAC and inhalation general anesthesia.

In the remimazolam group, remimazolam was administered at a rate of 6 mg/kg/h until the loss of consciousness, followed by at a maintenance dose of 1 mg/kg/h, and adjusted. In the sevoflurane group, general anesthesia was induced with propofol 1-2 mg/kg and maintained with 1-2 minimum alveolar concentration sevoflurane. Following the loss of consciousness, laryngeal mask airway (LMA) insertion or endotracheal intubation was performed after administration of intravenous 0.3-0.6 mg/kg rocuronium. Remifentanil was administered using a target-controlled infusion (TCI) at effect-site concentration [Ce] of 3.0 ng/ml and adjusted to maintain the ANI scores in the range of 50-70 in both groups. The primary outcome was net anesthesia time, calculated by excluding the procedure time from the total anesthesia time.

Till now, 11 patients were enrolled. The net anesthesia time was significantly shorter in the remimazolam group than in the sevoflurane group (14±7 vs. 25±4 min, p=0.023). The operating room occupancy time was also significantly shorter in the remimazolam group than in the sevoflurane group (32 ± 10 vs. 49 ±11 min, p=0.039). The procedure time, time to loss of consciousness and regaining consciousness, admission day were similar between the groups.

Remimazolam-based MAC proves to be a safer alternative for general anesthesia during TURBT.

Achieving surgical anesthesia for above the knee amputation (AKA) utilizing peripheral nerve blocks (PNB) is challenging due to the complex innervation of the thigh compartment. At present, there is limited literature on the use of PNB as the sole anesthetic technique for AKA. This paper presents a case of a 61-year-old female and known case of Neurofibromatosis Type 1 who was scheduled for AKA due to a malignant peripheral nerve sheath tumor in the right patellar area (Fig 1). The tumor was causing anemia and sepsis due to active bleeding and infection. The patient also developed hospital-acquired pneumonia.

The patient was started on Midazolam and Fentanyl followed by target-controlled infusion of Propofol for sedation. Five nerve blocks were performed: femoral, lateral femoral cutaneous, obturator, subgluteal sciatic, and posterior femoral cutaneous. Ultrasound, nerve stimulator, and pressure monitor guidance was utilized. The concentration and volume of Ropivacaine was adjusted based on the patient’s weight (38 kg). A femoral nerve catheter was placed post-operatively for supplemental pain control.

The patient was hemodynamically stable throughout the procedure, with no recall of intra-operative events including the conduct of nerve blocks. She had good post-operative pain control and was subsequently discharged on the fifth post-operative day.

This case report highlights PNB as a safe and effective anesthetic technique for AKA in patients with contraindications to neuraxial and general anesthesia. Specific block of the posterior femoral cutaneous nerve (Fig 2), which was not described in past literature on PNB for AKA, was performed in this case.

Ultrasound-Guided Regional Anaesthesia (UGRA) occupies a wider curriculum role, with UK anaesthetic trainees expected to independently perform a variety of blocks upon completing training. UGRA is challenging to master; high-quality feedback is vital in enabling skill acquisition(1). Retrospective Video Review (RVR) is associated with a flatter learning curve when learning procedural skills(2), but has yet to be evaluated in UGRA. We aimed to evaluate the feedback process and further improve it.

We conducted a national survey evaluating UK anaesthetists’ attitudes and practices regarding feedback provision in UGRA training. Concurrently, we developed a feedback framework incorporating RVR of the ultrasound block video specifically performed by the trainee. This was trialled in a tertiary orthopaedic hospital as a Quality Improvement Project, with trainer-trainee pairs interviewed on their experience using this educational tool.

Of the 126 survey respondents, 62% were trainers and 38% were trainees. 36% of trainees were ambivalent/dissatisfied about feedback quality. Trainers were receptive to a feedback tool. Time taken to teach; clinical turnover; managing awake patients were barriers to feedback provision. 6 trainers and 4 trainees trialled the educational tool. Common themes included: greater objective evidence to base feedback on; increased discussion detail/quality (particularly with awake patients); benefits of checklist/structured approach.

This is the first national survey on UGRA feedback, and the first preliminary evaluation of RVR use incorporated into a UGRA feedback framework. There is further scope to develop our tool with the aim of validating it, such that it may be utilised widely to improve trainee-trainer experience.

Elderly patients with hip fractures coming for surgical fixation pose unique challenges and require a judicial fine balance. Motor weakness imposed by traditional nerve blocks (FIB and FNB). Although these conventional nerve blocks provide good pain relief they impose risks of more motor weakness and that induces delay in rehabilitation and postoperative falls.

We thus imposed newer motor-sparing blocks (PENG, SIFI, and LFCN blocks). Over two years, we conducted an audit in which time we saw shifting away more toward newer motor sparing blocks.

We analysed the data of 118 patients who underwent hip fracture surgery and received GA and or SA with traditional and/or newer motor-sparing nerve blocks. Patients who received any form of nerve blocks had a longer time to rescue analgesia and lesser requirement for both on-demand as well as regular opioids. SPatients who received nerve blocks cooperated better with physiotherapy once they gained motor power, but this resulted in a bit higher limb weakness and postoperative falls, especially in the traditional block group.

Overall the use of nerve blocks has improved the immediate pain as well as reduced the opioid requirements. The use of adjuvants in nerve blocks and the promotion of motor-sparing nerve blocks in ED and theatre will possibly improve further outcomes.

Postoperative pain management following laparoscopic liver resection remains a significant challenge despite advancements in anesthesia techniques. This study aimed to investigate whether a single-shot erector spinae plane block (ESPB) or posterior quadratus lumborum block (QLB) could enhance postoperative analgesia in the first 24 h after surgery.

A prospective, double-blinded, randomized controlled trial was conducted at a single tertiary care center between August 2022 and January 2024. One hundred fourteen patients scheduled for laparoscopic major liver resection due to malignancy were recruited. Patients were randomly assigned to the control, ESPB, or QLB group in a 1:1:1 ratio. Both the ESPB and QLB groups received 40 mL of 0.5% ropivacaine (20 mL on each side). The primary outcome was cumulative opioid consumption during the first 24 h after surgery. Secondary outcomes included pain scores and intraoperative and recovery parameters.

The average cumulative opioid consumption at 24 h after surgery was comparable among the groups. No significant intergroup differences were observed in cumulative opioid consumptions at all time-points (Figure 1). Pain at rest was significantly different in the PACU (PACU admission: P = 0.012; PACU worst pain: P = 0.012; PACU discharge: P = 0.006) and at 48h after surgery (P = 0.006). For pain when coughing, differences among the three groups were noted only at PACU admission and PACU worst pain (P = 0.002, P = 0.006, respectively)

Neither ESPB nor posterior QLB significantly reduced the cumulative opioid consumption at 24 h after laparoscopic major liver resection.

Thoracotomy is a painful surgical intervention characterized by a high incidence of chronic pain that can be reduced with an aggressive analgesic therapy, justifying the use of thoracic epidural analgesia with opiates and local anesthetics for their efficacy and the relatively high benefits, Unilateral intercostal nerve blocks are quick and simple. Single injection for two or three intercostals spaces. Xylocaine patch application can be a powerful analgesic adjunct to existing analgesic agents

Control intercostal group (Group I, n=20): Patient in this group will receive a dose of 5 ml bupivacaine 0.5% peri-neurally in each space. - Xylocaine patch (Group xylo, n=20): Patients in this group will receive xylocaine patch. Two patches to applied for each patient for 24 hours then to be removed. When sufficiently awake for pain assessment VAS at 2, 4, 6, 8, 12, 16, 24 hours postoperatively. The time to the first request of rescue postoperative analgesic will be: “the time interval between the onset of recovery and the first request to postoperative analgesia”. Cumulative 24 hours analgesic consumption of and morphine will be recorded. Ramsay score for assessment of sedation at the same intervals for VAS.

there was significant difference in the first rescue analgesia with more than 8 hours postoperative in xylo group and only 2 hours in I group. total amount of opioids consumed in 24 hours following surgery in xylo group was significantly lower than the other group

xylocaine patch is an effective non invasive alternative in control of post thoracotomy pain

In 2013 the lead author started carrying out breast augmentation under local anaesthetic with sedation on a day case basis in a stand-alone ambulatory surgical centre. Subsequently a total of 7 surgeons have carried out breast enlargement at the clinic using this technique. A retrospective review of the first 1019 patients was performed.

Inclusion criteria for breast enlargement under LA with sedation was ASA 1 or 2 and BMI less than 32. The procedure was carried out using local anaesthetic infiltration with anaesthetist delivered conscious sedation using a combination of propofol and fentanyl and no airway management. Standard breast enlargement precautions were undertaken. Patients were contacted though Survey Monkey survey to determine satisfaction with the procedure.

Average age of the patients was 32.7 years. 686 patients (67.3%) had had children. 897 patients (88%) were ASA 1. None were ASA 3. 132 patients (13.0%) were smokers. Average implant size was 380cc, 327 (32%) being anatomical and 692 (68%) round. 91 patients(8.9%) had submammary implants, the rest dual plane.In t Ierms of complications 32 patients had infections which generated a positive microbiology culture. These were mostly stitch abscesses, however, 9 patients had implants removed, washed and replaced. Subsequently 2 of these implants required removal and replacement some months later and a further 2 presented with capsular contracture years later.

Primary breast augmentation under local anaesthetic with sedation is a viable alternative to general anaesthesia. We found complication rates were low in comparison to studies quoting complication rates for general anaesthetic breast augmentation,

Pericapsular nerve group (PENG) block gathered good results for pain relief in hip fracture. We compared the efficacy of PENG block over sedation technique in positioning for sub-arachnoid block (SAB) in patients with intracapsular fracture neck of femur (NOF) for hemiarthroplasty.

Sixteen patients in each group for hemiarthroplasty were consented for PENG block (Gr-A) and sedation (Gr-B) prior to SAB. Patients with mental obtundation and conditions contraindicated for SAB were excluded. Ultrasound guided PENG block with 20 ml of 0.25% of bupivacaine administered in Gr-A. SAB (hyperbaric bupivacaine 0.5% 2.2 ml) commenced in lateral position 10 minutes after PENG block with fracture side up. Sedation with fentanyl, midazolam and propofol were given in Gr-B prior to positioning for SAB. Visual analogue score (VAS) for pain along with ease of positioning were assessed during SAB.

Mean age (79 yrs) and M:F ratio were identical in both groups. All patients were noted VAS 10 on minimal hip abduction on arrival. VAS reduced to 2 (12pt), 3( 4pt) 10 minutes after PENG block in Gr-A on positioning for SAB. While 37.5%(6pt) of Gr-B required additional boluses of sedation due to VAS 8 and above during positioning for SAB. Successful SAB commenced in 100% patients in Gr-A compared to 87.5 in Gr-B. No pain was observed in Gr-A on returning to supine immediately after SAB compare to 10 pts in Gr-B.

PENG block provide an effective analgesia in patients with intracapsular fracture NOF for positioning for SAB over sedation.

In addition to general anaesthesia, central and peripheral blocks are preferred for analgesia during pancreatic surgery. We aimed to investigate the effects of epidural and erector spinae plane (ESP) blocks on intraoperative and postoperative pain, renal function, and haemodynamic variables in patients undergoing Whipple surgery.

The study participants were 65 ASAI-II-III patients aged 18–80 years who received general anaesthesia to undergo Whipple surgery. In the epidural group, a thoracic epidural block was performed at the appropriate level between T8 and T10 in 37 patients; a catheter was placed. In the ESP block group, a bilateral thoracic ESP block was performed with the administration of 0.25% bupivacaine (20 mL) on each side (50 mg bupivacaine) under ultrasonography guidance. Patients in this group received 50 mg of dexketoprofen before surgery. Pain scores and side effects were recorded at 0 min, 15 min, and 30 min postoperatively. The patients' intraoperative and 6 h, 12 h, and 24 h postoperative urine outputs; preoperative and 48 h postoperative creatinine levels; and 24 h postoperative systemic immune inflammation index (SII) values were recorded.

There was no statistically significant differences were noted between the groups in terms of demographic data. Hourly Ultiva consumption, VAS (visual analog scala) values, and creatine output levels were significantly higher in the ESP block group than in the epidural block group.

Epidural block reduced postoperative pain scores and intraoperative opioid consumption. We believe that the efficacy of the ESP block can be better evaluated using quality of life and recovery scores.

Exploring neurobiological pain markers is crucial for tailored therapies. Non-invasive methods like EEG, pupillometry, and NOL provide nociception-related perioperative insights. This study examines their correlation with post-thoracic surgery pain, focusing on preoperative alpha EEG oscillations (Peak Alpha Frequency, PAF), pupillometry, and NOL's predictive potential.

Patients over 18 undergoing major thoracic surgery participated in this study. Pupillometry using the NPi-200 pupillometer assessed parameters like contraction velocity (CV), maximum contraction velocity (MCV), contraction percentage change (CH%) and dilation velocity (DV). Ambient light was measured with a commercial luxmeter. Scalp EEG was collected preoperatively using a 7-electrode EEGrid-headset. Data were processed using EEGLAB and FieldTrip, including preprocessing, frequency decomposition, and estimation of sensorimotor PAF. NOL data from the PMD-200 system were analyzed. General anesthesia was standardized, and opioid doses were calculated. Pain was assessed using an 11-point NRS at PACU, DN4 questionnaire, and NRS scale at one- and three-months post-surgery.

Data from 19 participants (10 males, mean age 68.05) demonstrated strong correlations between PACU pupillometry parameters and DN4 scores at one- and three-months post-surgery. Additionally, NRS scores at one and three months were significantly correlated with PACU pupillometry indices (table). Conversely, no significant associations were found between NOL or EEG data and pain outcomes.

Immediate postoperative pupillometry strongly correlates with chronic and neuropathic pain at one- and three-months post-thoracotomy, suggesting its predictive potential for long-term outcomes. However, preoperative PAF and intraoperative NOL did not correlate with postoperative pain, emphasizing pupillometry's utility in personalized pain perception and management, warranting further validation with larger cohorts.

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.

Although laparoscopic cholecystectomy (LC) is a minimally invasive procedure, pain may occur in the postoperative period. The subcostal transversus abdominis plane (sTAP) block has been shown to provide effective postoperative analgesia in laparoscopic surgery. External oblique intercostal plane (EOIP) block has also been proposed as a novel technique to provide analgesia for upper abdominal surgeries. Our study aims to investigate the effect of EOIP block on postoperative pain score and opioid consumption in LC compared to sTAP block.

After Ethical board approval, 80 patients were randomized to receive either EOIP or sTAP block. Bilateral blocks were performed with 20 ml of 0.375% bupivacaine in both groups after the induction of general anesthesia. All groups received standard general anesthesia and postoperative analgesia. Patients were evaluated in the PACU and postoperatively at 1st, 2nd, 4th, 8th, 12th, and 24th hours. Pain scores and opioid consumption were measured.

There was no statistical difference between VAS scores at rest and active movement at all measurement times (p>0.05). Opioid consumption in the first 4 hours was less in the sTAP group than in the EOIP group (p=0.039) However, there was no statistical difference in opioid consumption at 24 hours (p=0.215). There was no statistical difference between the groups in terms of rescue analgesia or first analgesic need (p>0.05).

After LC, the analgesic effect of the EIOB block is not superior to the STAP block in terms of pain scores and opioid consumption. EOIB can easily be used as part of multimodal analgesia in LC procedures.

This study aimed to determine the learning curve for an ultrasound-guided popliteal block and the transference of this training to a real patient situation.

After approval by the ethics committee, ten first-year anesthesia residents were recruited to participate in a simulated-based training program to perform a single shot in plane popliteal block. (NCT06081790) Training consisted of 10 individual sessions, with direct feedback from the instructor, with a specific Laerdal® sciatic popliteal block phantom, lasting one hour and distributed weekly. At the end of each session, the resident’s performance was assessed. Residents were videotaped while performing the block, which was to be evaluated using a validated global rating scale (GRS). Additionally, a tracking motion device (ICSAD) attached to the operator's hands recorded the total distance traveled by both hands (Total Path Length=TPL) and total procedure time (TPT). One week later, the same assessment was done on a real patient.

Ten residents completed the training and the assessments. Median values of GRS scores significantly improved from 14 to 28 through the training (p=0.02) (Figure 1). Regarding ICSAD scores, TPT improved from 126 to 59.5 seconds (p=0.004), and TPL improved from 11.06 to 9.3 meters (p=0.432). We found no significant differences between the last simulated session and the subsequent measurement in an actual patient.

This simulation-based training program significantly improves residents’ proficiency in an ultrasound-guided popliteal block. The learning curve plateaued at session 7, and this improvement was transferred to the real patient setting.

Ethyl chloride spray is the mainstay of assessment of neuroaxial blockade in obstetric anaesthesia, but its use is controversial when more sustainable, greener and we argue, cheaper, alternatives are available, such as the CoolSticks.

This project combined a literature review, user satisfaction survey and a quarterly review of financial implications after CoolSticks were used to assess neuroaxial blockade instead of Ethyl chloride spray.

During the period of January – April 2024, CoolSticks were used in obstetric theatres instead of Ethyl Chloride spray at our trust, saving 1676.84KgCO2e and £2095.02 compared with the previous quarter (excluding the one-off purchase cost of the CoolSticks). Our user satisfaction survey showed 97% of obstetric anaesthetists were confident with the use of the CoolSticks for assessing dermatomal level, with a 100% of patients accepting its use clinically.

We established that CoolSticks were superior to Ethyl chloride spray in both cost effectiveness and user satisfaction, whilst removing the health risks associated with the use of the spray. Due to the success of the CoolSticks, it is now used as the first line method of assessing neuraxial block at our obstetric unit. Our goal is now to role out the use of CoolSticks trust-wide, including areas such as orthopaedics and trauma, to help reduced anaesthetic-related environmental pollution whist saving funds.

Erector Spinae Plane Block (ESPB) was introduced in 2016 as an analgesic block for thoracic neuropathic pain. Later, it was incorporated as one of the technics of multi-modal analgesia for peri-operative pain control in thoracic surgeries. Following that Lumbar ESPB emerged, which is widely being used as an analgesic & anesthetic block for spine, abdomen, inguinal and lower limb surgeries. Recent development is Sacral ESPB which is being used as an analgesic and anesthetic block for Ano-rectal, sacral, and hip surgeries. We would like to explore further on the anesthetic potential of sacral ESPB, as it is a novel technic, and it can be beneficial in high-risk patients for the conventional methods of Anesthesia.

We reviewed all the articles which were published about Sacral ESPB, as an anesthetic block. We could find a Single-Centre Retrospective Cohort Feasibility Study which included 10 patients who underwent sacral reconstructive surgeries, as case report which included 2 patients who underwent ano-rectal surgeries and another case report which included a patient who underwent hip surgery, solely under sacral erector spinae plane block.

All the above patients tolerated the procedures very well with minimal sedation and they had effective post-operative analgesia as well.

Sacral erector spinae plane block can be effectively used as an anesthetic technic in patients undergoing sacral, anorectal & hip surgeries. However, most of the information is available only from case reports. We need further RCTs to establish their effectiveness as an anesthetic block.

Critical limb ischemia is limb pain occurring at rest or impending limb loss as a result of lack of blood flow to the affected extremity. CLI pain is challenging to control despite multimodal pharmacologic analgesia and surgical intervention. We describe the successful use of an infraclavicular nerve catheter to control severe refractory ischemic upper limb pain in a patient with metastatic lung cancer for whom surgical and pharmacological intervention was unsuccessful.

A 56-year-old female with metastatic lung adenocarcinoma was admitted with left sided finger pain and discolouration. CT left upper limb angiogram demonstrated severe focal stenosis of the proximal left subclavian artery, compounded by acute arterial occlusion of left radial and ulnar arteries on ultrasound scan. She was commenced on intravenous heparin and underwent surgery emergently. Unfortunately, attempts at re-establishing flow down the ulnar artery were unsuccessful. She subsequently developed dry gangrene and experienced severe neuropathic pain.

Despite opioid escalation, rotation and use of neuropathic adjuncts and non-pharmacological management with music therapy, her pain was poorly controlled. Opioid escalation was limited by opioid toxicity which manifested as drowsiness with myoclonic jerks. A tunneled infraclavicular brachial plexus catheter was then performed and ran at 4ml/hr of 0.2% Ropivacaine. The patient reported pain relief and was transitioned off opioids. She remained comfortable and subsequently demised.

Ultrasound-guided regional techniques are a promising therapeutic option especially with failed surgical interventions for cancer pain. Future research into coordinating access to such procedures in the inpatient, emergency department and hospice settings may be beneficial.

Unplanned readmissions following discharge are burdensome to patients, family, and health care systems. This study aimed to investigate whether uncontrolled pain on discharge-day increased the likelihood of unplanned readmissions in a surgical population at a tertiary cancer hospital.  

This quality improvement retrospective study analyzed adult (age ≥ 18 years) inpatient data including pain assessments during hospitalization and discharge over a 12-month period, yielding a total of 249,458 inpatient hospital days and 26,677 hospital discharges (alive), of this 7993 were surgical discharges. The primary outcome of interest was 30-day unplanned readmissions for any reason. We defined uncontrolled-pain on the day of discharge in two ways ─ a) documentation of ≥3 consecutive severe-pain scores (≥7 on 0-10 scale) (severe-pain-3C); and b) severe-pain documented as the last score prior to discharge (≥7 on 0-10 scale) (severe-pain-L).

On discharge-day, the frequency of surgical patients discharged with uncontrolled-pain were 3.2% and 3.5% for severe-pain-3c and severe-pain-L, respectively. Figure-1 demonstrates monthly trends for uncontrolled pain during hospitalization and discharge-day, which remained stable. The overall 30-day hospital readmission rate for surgical patients was 9.5% (Figure-1). The odds-ratio for 30-day hospital readmission with uncontrolled pain on discharge was 2.69 (1.99 - 3.63), P< 0.0001 for severe-pain-3C and 2.95 (2.182-3.98), P < 0.0001 for severe-pain-L(Figure-2) and adjusted odds ratio (Figure-3).

Uncontrolled pain on discharge was shown to be positively associated with 30-day all-cause readmission. These findings support the need for further research, including the development of targeted discharge planning interventions that prioritize timely follow-up and management of post-discharge pain

Introduction: Implementing an intrathecal drug delivery system (IDDS) in a patient diagnosed with von Willebrand disease (vWD) necessitates meticulous planning due to the high risk of bleeding complications.

Case report: This case involved a 55-year-old woman previously diagnosed with complex regional pain syndrome. Initially, she underwent spinal cord stimulation (SCS) without incident. However, after 28 months, the device was removed due to malfunctioning electrodes, and she opted for an IDDS. Following SCS removal, epidural patient-controlled analgesia was administered as a bridging therapy until the IDDS could be implanted. Compared with the SCS procedures, significant bleeding occurred during this phase. Although the patient had cirrhosis, her liver function and coagulation profiles were normal at the time. Nonetheless, an elevated PFA-100 test prompted referral to a hematologist, who suspected vWD. The hematologist recommended pre-procedural intravenous administration of a mixture of 0.3 ug/kg desmopressin and 50 mL normal saline over 30 to 40 minutes. Additionally, the use of cryoprecipitate or fresh frozen plasma (FFP) was advised if there was any history of bleeding. Given her recent frequent bruising, two pints of FFP were administered. After the preoperative administration of desmopressin in the waiting room and the initiation of FFP, she was transferred to the operating room where the procedure was performed under aseptic conditions without any complications.

Conclusion: With careful preoperative preparation and vigilant perioperative management, IDDS implantation in patients with vWD can be conducted safely and effectively, mitigating the inherent risks associated with this condition.

To report a case of a bilateral ultrasound-guided rectus sheath block used as the main anesthetic technique in a patient with ASA score III undergoing umbilical hernia repair surgery.

A 75-year-old patient with a history of severe COPD (FEV-1 Pred. = 36%), pulmonary hypertension (PASP = 60mmHg), atrial fibrillation, hypertension, diabetes mellitus and a BMI of 40.4 kg/m2, came in for umbilical hernia repair surgery. Due to the patient’s significant perioperative risks, a bilateral ultrasound-guided rectus sheath block was elected as the main anesthetic technique. Preoperatively, under sterile conditions, with the patient in supine position, a low-frequency curvilinear transducer was placed transversely above the umbilicus approximately 1 cm lateral to the midline. The rectus abdominis muscle (RAM) and posterior rectus sheath were identified. The needle was inserted in-plane and guided through the RAM until the tip was placed posterior to the RAM and anterior to the posterior sheath, where 25ml of ropivacaine 0,375% was administered. The technique was repeated on the contralateral side.

Sensory block of dermatomes T9-T11 was achieved. The surgery was well tolerated with minimal IV sedation (20mg of ketamine and 2 mg of midazolam) and additional local infiltration of 20ml lidocaine 1,5%. No adverse effects were recorded.

Bilateral ultrasound-guided rectus sheath block is an effective regional technique, allowing this high-risk patient to undergo umbilical hernia repair surgery, while avoiding general anesthesia and central neuraxial blockade.

Erythromelalgia, a rare disorder categorized as an orphan disease, presents significant diagnostic and therapeutic challenges. The disease manifests in episodic flares characterized by burning pain, erythema, and elevated skin temperature, primarily affecting the extremities, particularly hands and feet. Two etiologies are recognized: primary erythromelalgia, with an autosomal dominant inheritance pattern, and secondary erythromelalgia, which is often associated with underlying conditions such as neoplasms. The pathophysiology of erythromelalgia is likely due to a complex interplay between neural and vascular dysregulation. Unfortunately, most cases demonstrate limited responsiveness to pharmacological interventions, and the efficacy of pain management strategies exhibits substantial variability.

A 69-year-old male with a history of neuroendocrine tumor in the pancreatic tail – surgical removed – and low-risk MGUS of the IgG lambda subtype, was referred to a chronic pain consultation for management of neuropathic pain associated with erythromelalgia. Despite prior trials of various pharmacological interventions, including treatment for the underlying conditions, the patient reported minimal improvement. Application of a capsaicin 8% patch to the hands and feet for a 60-minute duration was proposed as a potential treatment modality.

Following the initial application, the patient reported a sustained improvement in both pruritus and burning complaints for a period of six weeks. During treatment, supplementary applications of the capsaicin 8% patch was done with an interval of eight weeks, resulting in further symptomatic improvement.

The capsaicin 8% patch emerges as a promising therapeutic modality in the management of secondary erythromelalgia. Notably, each application appears to confer progressively longer durations of pain relief.

Effective postoperative pain management is crucial for pediatric patients undergoing thoracic surgery, in terms of early discharge time and reducing the risk of complications.

After approval of ethic commitee (2024/58), between April 01, 2023 and April 01, 2024, pediatric patients who underwent thoracotomy were listed and retrospective data were obtained. Demographic data, type of surgery, duration of surgery, postoperative pain modality, pain scores within 24 hours, hospital discharge time were recorded from the patients' files.

A total of 18 patients, 66.7% (12) male and 33.3% (6) female, were included in the study. The ages of the patients ranged from 0.1 (28 days) to 17 years with a mean age of 11 years and a median age of 14 years. Video-assisted thoracic surgery (VATS) was performed in 77.8% and thoracotomy in 22.2%. The most common indications for surgery were bulla excision with 44.5% (8 patients), diagnostic thoracoscopy with 16.7% and empyema drainage and hydatid cyst with 11.1%. Postoperative block was performed in 38.9%, erector spina plane block in 71.4% and serratus anterior procedure in 28.6%. The 1st, 6th, 12th and 24th hour resting VAS scores of the patients who underwent block procedure decreased over time, while dexmedotomidine infusion and ketamine infusion were given to two patients who could not be evaluated. Post-op discharge time (days) and length of hospital stay were 7 (2-30), 11 days (3-59) (median, min-max), respectively.

Further research and implementation of tailored pain management protocols are warranted to enhance postoperative recovery and overall patient satisfaction in this population.

Pleurectomy/decortication (P/D), for malignant pleural mesothelioma is maximally invasive surgeries, which causes the prolonged length of hospitalization after surgery. Previous studies reported that regional anesthesia in addition to general anesthesia likely contribute to shorten hospital stay after surgery with reduction of acute postoperative pain. Association between the continuous intertransverse process block for postoperative analgesia and the length of hospital stay after P/D, however, has not been evaluated. This study aims to evaluate the association between postoperative analgesia using continuous intertransverse process block and shorter postoperative stay after P/D.

In a single-institutional observational study, adult patients undergoing P/D under general anesthesia with single-injection regional block, who received either continuous intertransverse process block or continuous intravenous (IV) fentanyl infusion after surgery for postoperative analgesia, were enrolled from March 2022 to February 2023. Multivariable logistic regression analysis was performed to determine the association between perioperative variables and length of hospital stay.

In all patients (n=60), postoperative analgesia was performed using either continuous intertransverse process block in patients (n=19) or continuous IV fentanyl infusion (n=41).The result revealed shorter length of hospital stay after surgery was significantly associated with continuous intertransverse process block (P=0.007). In subgroup analysis, Both C-reactive protein level on postoperative day (POD) 3 was lower (P=0.017), and postoperative pain on POD 3 was lower (P=0.045) in patients with continuous intertransverse process block.

Postoperative analgesia using continuous intertransverse process block is likely associated with the reduction of the length of hospital stay after P/D under general anesthesia.

Background: Adopting ultrasound-guided regional anesthesia (UGRA) is challenged by the need for standardized training, particularly in resource-limited settings like the Philippines. Simulation-based workshops using live-anesthetized porcine models present an innovative approach to enhance anesthesiologists' proficiency in UGRA, potentially improving patient outcomes and procedural efficiency. Objectives: This study aimed to assess the impact of simulation-based training using live-anesthetized porcine models in enhancing anesthesiologists' proficiency in performing ultrasound-guided Plan-A blocks.

Methods: Following Institutional Animal Care and Use Committee approval, this retrospective, quasi-experimental study used the responses from a validated survey of 29 anesthesiologists of different skill levels who participated in a workshop conducted at SLMC-BGC in October 2023 aimed at improving proficiency in performing ultrasound-guided Plan-A Blocks using live-anesthetized porcine models. Their demographic characteristics and pre- and post-workshop survey responses were gathered and quantitatively analyzed.

Results: Prior to the workshop, the proficiency of the anesthesiologists was measured in terms of basic sonoanatomy, ergonomics, equipment preparation, image acquisition, needle manipulation, optimal needle tip position, hydrolocation, overall confidence and anxiety level were all on the average. After the workshop, all these variables significantly increased to a high level (p <.001), while their overall anxiety level significantly decreased to a low level (p =.023).

Conclusions: The study underscores the value of simulation-based training in enhancing the proficiency of anesthesiologists in UGRA. The positive outcomes suggest that these models could be a potential educational tool integrated into regional anesthesia training modules, positively impacting patient safety and quality of care delivered in the Philippines and similar settings

Limb amputations are a significant consequence of major trauma, and can result in acute and chronic pain. Acute pain management is crucial for recovery and rehabilitation. Severe postoperative pain is a risk factor for developing chronic post-surgical pain, and is potentially modifiable. Evidence shows peripheral nerve blockade (PNB) reduces perioperative opiate consumption. Some studies suggest regional anaesthesia may decrease risk of chronic pain, but they are small and not specific to major trauma. This study aimed to identify acute benefits using PNB in major trauma patients undergoing limb amputations.

This retrospective study reviewed all patients who underwent limb amputation under Trauma and Orthopaedics at our tertiary centre between 21/07/2020 and 19/10/2023. We reviewed case notes to identify intraoperative analgesia, pre-operative and postoperative opiate requirements, and postoperative function qualified as engagement with physiotherapy.

69 patients were identified (64 lower limb amputation, 5 upper limb amputation). Surgical indications included traumatic injury (n=42), osteomyelitis (n=26), and chronic pain (n=1). 33% (n=23) received PNB catheter, 42% (n=29) received PNB single-shot, and 25% (n=17) did not get PNB.

This observational study demonstrated reduction in postoperative opiate consumption in patients receiving PNB, with lowest consumption in those receiving PNB catheter. PNB patients had higher rate of engagement with physiotherapy postoperatively. Limitations to this study were small cohort size, varied surgical indications and the no PNB group may have included more unwell or multiple injured patients. More data is needed to establish benefits of PNB.

An ideal analgesic regimen after Caesarean Section should provide high-quality maternal analgesia with minimal adverse effects, facilitating a prompt return to normal function. This study evaluate the effectiveness and safety of nalbuphine for patient-controlled intravenous analgesia (PCIA) after cesarean section.

Fifty parturients, aged 22-46 years old, weighing 50-80 kg, ASA Ⅰ or Ⅱ, scheduled for caesarean section with spinal anesthesia, were enrolled in this study. A bolus of nalbuphine 10 mg was intravenously injected as a loading dose at the post anesthetic care unit. PCIA was performed after this bolus dose. PCIA pump solution contained 120 mg nalbuphine diluted to 120 ml with normal saline. The pump was set up with a background infusion at a rate of 5 ml/h, 2 ml bolus dose and 15 min lockout interval. The VAS scores for pain at rest and during activity and uterine contraction pain, Ramsay sedation scores and adverse reactions were observed within 24 h after surgery.

The VAS scores for pain at rest and during activity and uterine contraction pain were all ≤4 points, the Ramsay scores were maintained at 2-3 points, hemodynamic parameters were maintained in the normal range, and no adverse reactions such as nausea and vomiting, drowsiness, hyperhidrosis, dizziness, pruritus, and respiratory depression occurred.

PCIA with nalbuphine given, according to the method mentioned above, has good feasibility when used for analgesia following caesarean section.

The nociception level index (NOL) is a novel nociception monitor, validated for adults, which has recently proved to detect the nociceptive stimuli in paediatrics that still waits for the clinical significance of this opportunity for the nonverbal age (1,2,3). In this case series, we aim to evaluate the effectiveness of the NOL monitor in guiding adequate perioperative analgesia in paediatrics and observe the relation between the NOL and the behavioural pain assessment scales (FLACC, CHIPPS).

After informed parenteral consent, thirteen cases received general anaesthesia to receive fracture surgery under NOL monitorization with a standard pain management protocol of 10 mg/kg (IV) paracetamol and 0,025 mg/kg morphine (IV). Additional morphine bolus doses were applied if only intraoperative NOL were over 25 or decided based on hemodynamics. Postoperative pain was evaluated using FLACC and CHIPPS scores at the PACU, 2nd, 6th, 12th, and 24th hours after surgery. A rescue analgesic was given if the pain score was four or higher.

The demographic data present 13 cases (Table 1). Intraoperative analgesic doses were only needed when NOL was over 25 (Table 2). There was no time when hemodynamic changes indicated pain, and the NOL value was low. Postoperative scores were compatible with low NOL before arousal except for cases 8 and 10, having a high FLACC score with a low CHIPPS at the same time.

NOL guidance would be valuable for ensuring intraoperative analgesia for nonverbal pediatric patients. However, additional randomized controlled analyses are needed to validate NOL monitoring in specific age groups.

Persistent Idiopathic Facial Pain (PIFP) is complex, both in its diagnosis and in its treatment, which currently lacks a gold standard. Recent studies approached the idea that an imbalance in Dopamine release and in D1,D2 receptors expression could be involved in chronic pain, rather than a simple Dopamine depletion. It was in fact demonstrated tjat there is an increase in D2 receptor availability and a decrease in D1/D2 ratio in the striatal dopaminergic system of PIFP animal models. This study aimed to retrospectively evaluate the efficacy of treatment with amitriptyline–perphenazine (a postsynaptic inhibitor of dopamine receptors) association in patients with severe PIFP.

In 2021, 31 patients with severe PIFP were given a regimen dose of amitriptyline–perphenazine, ranging between 10/2 mg and 20/4 mg. All patients were retrospectively analyzed for their pain intensity using a numerical rating scale (NRS) and for their quality of life using a SF-36 questionnaire. Non-normal distributed NRS results were analyzed using the Wilcoxon test for paired data, whereas normally distributed SF-36 questionnaire results were analyzed using the t-test for paired data. A p value < 0.05 was considered statistically significant.

Pain values, frequency of acute episodes and quality of life were found to be significantly improved. See tab 1.

The amitriptyline-perphenazine combination seems to be effective and well-tolerated by patients with PIFP, leading to a whole new therapeutic prospective. It is abundantly clear that dopaminergic pathways play a key role in pain modulation, whereas the underlying mechanisms have yet to be understood, requiring further investigation

Labor epidural analgesia is used to alleviate labor pain, and that depends on proper needle and catheter placement. This study aimed to assess the sensitivity of color flow Doppler (CFD) in confirming the position of the epidural catheter by utilizing two approaches: the parasagittal view (PSV) and the transverse view (TV).

This is a prospective observational design study. Women in labor were categorized into two groups according to their Body Mass Index (BMI). Group C consisted of women with a BMI <35, whereas Group O consisted of women with a BMI > 35. CFD was used to detect the flow in the epidural space. Data was collected and analyzed.

In Group C, 72.2% of patients showed flow detected by PSV, compared to 45.4% in Group O, with a p-value of <0.001. The sensitivity for detecting flow in the PSV in Group C was 70.45% versus 35.23% in the TV. Group O demonstrated a sensitivity of 53.33% in the PSV versus 8% in the TV. Within Group C, the specificity for detecting CFD was 11% in the PSV and 77.78% in the TV. In Group O, the specificity was 81.82% in the PSV and 95.45% in the TV. The PPV for the PSV and TV in Group C were 88.57% and 93.9%, respectively. In Group O, the PSV had a PPV of 91% versus 85% in TV.

CFD provides a valuable and readily available tool for accurately determining the placement of the epidural catheter in the epidural space during labor analgesia.

Background: Day case extremity surgery performed under regional anaesthesia has clear benefits in terms of efficiency and resource demand. For patients, avoidance of general anaesthesia and excellent post-operative analgesia can help with early oral intake, mobilisation and discharge. These benefits are maximal when patients undergo wide-awake surgery without any pre or intra-operative hypnotics. However, patients feel anxious at the prospect of being awake for surgery. Virtual reality has the potential to provide an immersive experience, transporting the patient away from theatre environment and help relieve anxiety during surgery. We describe a case series of 8 patients ranging from 16 to 82 years with varying levels of anxiety where VR was utilised to facilitate awake upper limb surgery Aim: To utilise VR headset to alleviate anxiety in adults undergoing awake upper limb surgery under regional anaesthesia.

Following consent, ultrasound guided nerve blocks were performed in all patients with one patient requiring 1mg of Midazolam to facilitate the block. In theatre, VR scenarios were commenced prior to surgery and continued for the duration of the procedure. Pre and post-operative pain and anxiety scores were recorded using VAS.

All procedures were completed without the need for intra-operative anxiolytic agents. In PACU, post-operative anxiety and pain scores were considerably lower compared to pre-operative scores. Rescue opioids were not required. VR was well tolerated with good patient satisfaction. Patients were discharged home the same day with simple analgesia.

We conclude VR could be a useful adjunct in minimising intra-operative sedation & anxiety during wide-awake surgeries.

Intrathecal Drug Delivery Systems (IDDS) provide targeted pain relief by delivering medication directly to the spinal cord, benefiting patients who do not respond to conventional treatments or experience severe side effects. However, the effectiveness and response patterns to IDDS between cancer-related and chronic non-cancer pain patients remain largely unexplored. This study aimed to compare the efficacy of IDDS between patients with cancer-related pain (C group) and those with chronic non-cancer pain (NC group).

Intrathecal Drug Delivery Systems (IDDS) provide targeted pain relief by delivering medication directly to the spinal cord, benefiting patients unresponsive to conventional treatments or experiencing severe side effects. However, the effectiveness and response patterns of IDDS between cancer-related and chronic non-cancer pain patients remain largely unexplored. This study compared the efficacy of IDDS in patients with cancer-related pain (C group) and chronic non-cancer pain (NC group).

Both groups showed significant increases in MEDD from baseline to 1-year post-implantation, with the C group requiring higher doses throughout the study period (Fig. 1). Similarly, both groups exhibited significant reductions in VAS scores; however, group C experienced greater and more sustained pain reduction (Fig. 2). A higher proportion of patients (42.9%) in the C group achieved a 50% or greater reduction in pain at 6 months compared with the NC group (12%, P = 0.04).

The patterns of pain control and changes in MEDD differed between the groups. Our findings suggest that while IDDS benefits cancer pain, its use in chronic non-cancer pain should be approached cautiously.

Epidural analgesia, commonly used to manage labor pain, requires informed consent due to potential complications. Our study investigates the effectiveness of pre-epidural explanations for informed decision-making and explores maternal preferences for information delivery.

A questionnaire-based study surveyed postpartum parturients who received epidural analgesia at Shaare Zedek Medical Center in Jerusalem. The questionnaire covered demographic details, technical birth aspects, satisfaction with explanations, familiarity with epidural procedure, and overall birth satisfaction. Responses were statistically analyzed with R to gauge information comprehension and awareness of risks.

Data derived from 146 questionnaires. A majority (85%) of parturients were satisfied with birthing experience and epidural effect, deemed explanations about the procedure from anesthesiologists and midwives sufficient (51.6%-86.6%), but did not receive a sufficient explanation regarding possible complications (71.7%-81.6%). Accordingly, awareness of life-threatening complications was low (<25%). Surprisingly, most parturients preferred not to receive prenatal explanations or in-depth information on complications (53-68%). Even when stratified by parity, or pain levels at signing, parturients remained averse to knowing complications or receiving prenatal explanations. However, we identified significant differences between first-epidural and return parturients, with the former reporting increased desire to receive guidance (36.7% vs. 19.6%, p=0.028).

Maternal satisfaction with current explanations on epidural is high, and interest in additional information before birth is limited. Furthermore, women favor not delving deeply into potential complications. While these findings are hospital-specific, as it primarily involves an orthodox Jewish obstetric population, expanding the study to diverse hospital settings could offer valuable insights.

TLIP blocks the dorsal rami of the thoracolumbar nerves, as they pass through paraspinal musculature. The ESP block is performed by depositing the local anaesthetic between the deep fascia of the erector spinae muscle and the transverse vertebral process targeting the dorsal rami. Both are proven useful for spine surgeries. This study compares injectate spread of these interfascial plane blocks to better understand their mechanisms and to establish if there is any difference in the drug spread.

Ultrasound guided TLIP or ESP block were given at L3 or L4 level in 4 cadavers (4 blocks each) with 20 ml of methylene blue. Classical TLIP was given between multifidus and longissimus and ESP was given between transverse process and erector spinae muscle. Anatomical dissection was carried out to look for spread to muscles, dorsal and ventral rami and epidural space

The dye spread has been demonstrated in Table 1. Higher number of dorsal rami at the origin were stained in ESP block. However, the branches of dorsal rami between multifidus and longissimus were stained in all the blocks with similar craniocaudal spread. No spread was seen in the epidural space

TLIP block is an effective alternative to ESP block for spine surgery. The dorsal rami branches between the erector spinae group of muscles were equally involved in both the blocks. Surgeries involving the back with midline incision and no lateral extension may be well covered by TLIP block which is easier and superficial than ESP block

Consent is an essential part of the pre-operative anaesthetic assessment. The AAGBI states that ‘information about (…) associated risks should be provided to patients’, specifically stating that ‘anaesthetists should record details (…) in the patient record’ [1]. Consent has importance in ethical, professional and legal aspects and is evidenced through documentation. At Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) it had been noted that consent for regional anaesthetic risks was poorly documented. An audit was therefore undertaken.

Over 11 weeks, the pre-operative anaesthetic notes of patients undergoing regional anaesthesia were reviewed. Recorded information included the anaesthetic type, grade of consenting anaesthetist and risks that were consented for. The results for neuraxial vs peripheral block were analysed separately, and the following found.

89 notes were reviewed: 64 neuraxial anaesthetics & 25 peripheral nerve blocks. The highest frequency of consented risk was 80% for both temporary and permanent nerve damage associated with peripheral nerve block, followed by block failure at 60%. Disappointingly, for neuraxial blocks post dural puncture headache was most consented for at only 58%. Graphs 1 & 2 further detail the frequency of consented for risks.

Despite consent for risks being integral to the pre-anaesthetic assessment for both patient and clinician safety, it is poorly undertaken. This puts patients at risk of an outcome they weren’t made aware of and it is therefore paramount that methods of improving consent documentation in WWL are implemented.

Femoral, sciatic, obturator, and lateral femoral cutaneous blocks have been used individually, but combined, they can provide more effective pain relief (1-3). Combination often requires multiple needle sticks, position changes, and increased time. We developed a novel 4-in-1 block, we are calling LEENA, to target all of these nerves from a single insertion site and aim to compare this to the more conventional adductor canal block.

This is a retrospective cohort study of patients undergoing lower extremity surgeries which compared patients that received the LEENA block versus a traditional adductor canal (AC) block. Matching was performed for age, weight, gender, ASA, medications used, and surgical procedure. Our primary outcomes were block time, perioperative opioids, pain scores, and strength testing 2 weeks after surgery. Data was analyzed using Stata and P values were calculated using the Wilcoxon rank sum, the Chi-square, or Fisher’s exact test.

62 patients received the LEENA block and were matched with 177 controls for a total of 239 patients. Baseline demographics were not different. The LEENA group received less opioids, had lower pain score, and required less ventilation support. Strength testing was also significantly better in the LEENA group compared to the controls 2 weeks after surgery.

The LEENA block patients had better analgesia, avoided airway manipulation in 15% of cases, and potentially improved functional outcomes two weeks after surgery. The novel block is feasible and may have significant advantages compared to the adductor canal block alone. Prospective studies are needed to study this novel approach further.

Many institutions are facilitating the use of outpatient pathways for total knee arthroplasty (TKA) and total hip arthroplasty (THA). Our primary purpose in this systematic review is to assess evidence regarding the impact of neuraxial anesthesia, periarticular injection (PAI), and peripheral nerve blocks (PNB) on patient-centered outcomes for outpatient TKA and THA.

A task force of Society for Ambulatory Anesthesia (SAMBA) and American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) experts in regional anesthesia participated in this endeavor. PICO (population, intervention, comparison, outcome) questions were engineered to address the use of neuraxial anesthesia, periarticular injection, and peripheral nerve blocks on time to discharge, time to first ambulation, and pain scores. A standardized systematic approach was used in the review of the literature. MEDLINE, Embase, and Cochrane databases were queried.

The literature search yielded 3010 studies; 239 articles were assessed to be valid for formulation of our review. Only 2 studies assessed outcomes in the outpatient setting. The use of spinal anesthesia is associated with decreased postoperative pain and length of stay. The use of PAI is supported in both TKA and THA. Peripheral nerve blocks can decrease pain even in the presence of PAI among TKA patients.

Overall, our findings indicate that, while evidence exists to support the use of spinal anesthesia, periarticular infiltration, and peripheral nerve blocks, more research is needed to assess the potential impact of these techniques in an outpatient arthroplasty setting.

Large, randomized trials in regional anesthesia are challenging for many reasons including cumbersome recruitment, high cost, and complicated logistics. Pragmatic trials integrated into routine clinical practice offer an alternative to traditional randomized controlled trials. They employ simplified logistics while retaining key elements like randomization thus enabling rapid enrollment of large numbers of patients at low cost. We present our experience successfully implementing a large, pragmatic trial in busy clinical practice with no additional research funding.

After IRB approval, patients were randomized to receive one of three “standard of care” regional block approaches for mastectomy on a monthly basis. Day-of-surgery study consent was obtained by the anesthesiologist and all trial-eligible patients received the randomized block regardless of study participation. Recruitment and participant details are presented.

Between 8/21/2019 and 4/4/2023, 1756 subjects were screened for eligibility; 1508 (86%) consented to trial participation; and 1506 subjects were included in the analysis (Figure 1). One patient (0.07%) experienced a block-related adverse event. 492 patients received paravertebral (PVB) blocks, 446 patients received combined PVB and interpectoral (PECS-1) blocks, and 567 patients received combined PECS-1 and serratus plane blocks. The three groups were extremely similar (Table 1).

Our results suggest that although selection bias is possible with monthly randomization and individual patient consent, it was not observed in this trial, perhaps expected given the very high percentage of eligible patients accrued (86%). Clinically integrated trials serve as a template for other investigations in regional anesthesia to investigate the optimal regional anesthetic technique for a particular procedure.

The prolonged use of opioid medications postoperatively can lead to physiological, psychological, and even social issues for patients. Some scholars have suggested that gaps in postoperative pain management may contribute to the development of persistent postsurgical pain. However, it remains unknown whether early intervention by pain physicians postoperatively may lead to long-term opioid use issues.

This retrospective cohort study utilized the Longitudinal Health Insurance Research Database of Taiwan from 2001 to 2018. Among 506,092 patients who underwent surgery and anesthesia, 277,658 were included in the final analysis after excluding those with missing data, obstetric or congenital surgical procedures, death or rehospitalization within 3 months post-surgery, and emergency surgeries within 3 months post-surgery. Among them, 33,984 received outpatient care from pain specialists within 90 days post-surgery, while 243,674 did not.

In both groups, the risk of long-term opioid use post-surgery was 1.716 (1.661-1.774), P < 0.0001. The risk of mortality within 3-12 months post-surgery was 0.793 (0.711-0.883), P < 0.0001. The risk of rehospitalization within 3-6 months post-surgery was 1.534 (1.469-1.603), P < 0.0001.

According to data from the Taiwan Pain Society, rehabilitation physician and anesthesiologist are the primary physicians involved in pain management in Taiwan. However, the majority of patients receiving rehabilitation care after orthopedic surgery, which is a risk factor for long-term opioid use, may contribute to the seemingly higher risk of long-term opioid use among patients receiving pain management. Further statistical analysis is needed to clarify this aspect.

Hip fractures in the elderly population necessitate effective pain management strategies to improve outcomes. Peripheral nerve blocks are recommended for their potential benefits in pain control and recovery. However, their utilization remains variable. This study aims to evaluate the incidence and determinants of peripheral nerve block use in elderly hip fracture patients, with a focus on timing and patient outcomes.

A retrospective analysis of patient charts from University Hospital and Victoria Hospital in London, Ontario, Canada, was conducted. The study included patients aged 65 years and older diagnosed who underwent emergency hip surgery between January 1, 2018, and February 29, 2024. Data on nerve block utilization, patient demographics, cognitive impairment, length of stay, and timing of block administration were collected. Statistical analysis, including chi-square tests, logistic regression, and propensity score matching, was performed to examine the factors influencing nerve block utilization.

Preliminary findings suggest suboptimal utilization of peripheral nerve blocks in hip fracture surgery patients, with fewer blocks administered during off-hours and weekends compared to standard weekday work hours. Despite an annual increase in block utilization, patients during off-hours were less likely to receive blocks, indicating variation in care.

This study highlights the need for optimizing the utilization of peripheral nerve blocks in elderly patients undergoing hip fracture surgery. Understanding factors influencing block administration, such as timing, patient characteristics, and cognitive impairment, is crucial for enhancing pain management practices and improving outcomes in this vulnerable population.

Hip arthroscopy causes severe pain the first hours postoperative, probably due to the stretching of the hip joint capsule during surgery. Postoperative pain control is often achieved by high doses of opioids. This may cause opioid related adverse events and prolong recovery. The nociceptors in the hip joint capsule are mainly located anteriorly where the obturator nerve innervates the anteromedial part. We hypothesized that a subpectineal obturator nerve block would reduce the postoperative opioid consumption.

Forty ambulatory hip arthroscopy patients were enrolled in this randomized, triple-blind controlled trial approved by the Danish National Center for Ethics. All patients were allocated to a preoperative active or placebo subpectineal obturator nerve block. The primary outcome was opioid consumption the first three hours. Secondary outcomes were pain, nausea, and adductor strength.

Thirty-four patients were analyzed. The mean intravenous morphine equivalent consumption was reduced by 40% in the subpectineal obturator nerve block group versus the placebo group, 11.9 mg versus 19.7 mg respectively (p<0.001). See figure 1. The hip adductor strength was significantly reduced in the active group versus the placebo group, with a relative pre-/postoperative adductor strength reduction, 80% versus 38% respectively (p<0.001). No other intergroup differences were observed regarding the secondary outcomes.

A subpectineal obturator nerve block significantly reduced the postoperative opioid consumption by 40% after hip arthroscopy in this randomized, triple-blind trial.

Modified thoracoabdominal nerve block through perichondrial approach (M-TAPA) is a novel truncal block first reported by Tulgar et al in 2019. It has been reported to anesthetize a broad thoracoabdominal area; however, the neuroanatomical mechanisms remain unclear. Therefore, we conducted a volunteer study employing magnetic resonance imaging (MRI) to investigate the diffusion pattern of the local anesthetic responsible for extensive sensory area.

This study was approved by the Institutional Review Board of Hokkaido University Hospital. Three healthy male volunteers were involved. Bilateral M-TAPA was performed, administering 25 mL of Gadavist® containing 0.15% levobupivacaine on each side. The local anesthetic was precisely injected between the origin of the transversus abdominis muscle and the costal cartilage following Tulgar's description. One hour following the administration, the sensory area and local anesthetic diffusion were assessed using pinprick tests and MRI, respectively.

The 6 blocks in the 3 volunteers were evaluated. The sensory loss areas at 1 hour after M-TAPA were; T9, T9–10, T9–10, T8–9, T9, and T9–10. No effect was observed in the lateral area. The MRI revealed that local aneshtetic was distributed in the transversus abdominis plane near the injection point, and the compartment on the surface of the parietal peritoneum.

In this study, the sensory loss of M-TAPA was limited to the T8–10 in the anterior abdominal wall. Also, MRI tests did not detect a local anesthetic diffusion pattern that could lead to broad anesthetized area. These results indicate the necessity of caution in presuming the extensive anesthetized area of M-TAPA.

Following a previous audit into the management of rib fracture patients over 12 months (Jan-Dec 2021) an updated thoracic trauma protocol was introduced including offering a new ESP catheter service. We completed a re-audit of all rib fracture patients over a 12 month period to assess the impact, with audit department approval.

136 patients were identified presenting with rib fractures between October 2022 and September 2023. Data was collected from patient records on demographics, frailty, length of stay, rib fracture scores, type of analgesia, complications and appropriate referrals made. We also analysed those receiving ESP catheters in more detail (n=10).

Our dataset showed significantly less patients requiring ventilation, and trends towards reduced length of stay, critical care admission, and chest infection (see table 1). More patients were routinely reviewed by critical care outreach and the pain team. Patients having ESP catheters showed lower pain scores after insertion (see table 2 and chart 1). Interpretation requires caution due to less bilateral fractures in the re-audit cohort.

Following introduction of an updated rib fracture protocol, including a new ESP catheter service, we have shown potential improvements in key outcomes but also faced challenges in implementation. During this transitional period we faced real-world hurdles including trialling different kits, procuring appropriate pumps, provision of relevant training for anaesthetists and ward staff, and gaining departmental buy-in. Despite this, results are promising and we hope that now it's more established we can improve utilisation of the ESP service and our time to insertion prior to re-audit.

Scalp blocks have been described for analgesic management in craniotomies, traditionally performed using anatomical landmarks (ALGSB). In this study, we evaluated the effectiveness of ultrasound-guided scalp blocks (UGSB) compared to ALGSB in patients undergoing craniotomy.

An observational prospective cohort study was conducted to compare postoperative analgesia in patients who received scalp blocks using anatomical landmarks versus ultrasound guidance (figure1). Patients who underwent craniotomy and received total intravenous general anesthesia were included in the study. The primary outcome measured was adequate pain control, defined as a pain score of less than 4 on the numeric rating scale. Secondary outcomes included total postoperative opioid and non-opioid analgesic consumption.

A total of 111 patients were included in the analysis, with 59 and 52 patients receiving echo-guided and landmark-guided scalp blocks, respectively (Table 1). Adequate pain control was achieved in 80% of the patients at 6 h, 71% at 12 h, and 70% at 24 h postoperatively. The echo-guided group demonstrated significantly better pain control at 24 h than the landmark-guided group (84.7% vs. 53.8%; p<0.01). Although both groups showed low opioid use in the first 24 h, the ultrasound-guided scalp blocks group exhibited a significant reduction in morphine consumption at 24 h compared to the landmark-guided group (3 vs. 10 mg; p<0.001)(table 2).

Ultrasound-guided scalp blocks are an effective alternative to postoperative analgesia in patients undergoing craniotomy. Ultrasound guidance significantly improved postoperative pain control at 24 h and reduced opioid consumption compared to anatomical landmark-guided scalp blocks.

Regional anaesthesia is a core element of the Royal College of Anaesthetists curriculum and a key component as part of an independent anaesthetists practice (1,2). In our region, provision of regional anaesthesia training can be variable, therefore we created Sonoclub North West, targeting UK anaesthesia trainees aiming to improve their confidence, knowledge and skills. (3).

The course was divided into six monthly 3-hour sessions and focused on meeting the teaching standards for the RCOA curriculum for senior trainees. We divided 10-12 trainees into small groups. Each session started with theory-based teaching, including ergonomics, consent and risks, local anaesthesia (LA) choices for blocks, nerve stimulator use, LA adjuncts use and management of complications. The trainees then drew out the anatomy of nerve blocks, to reinforce their theoretical knowledge. The practical aspects focused on needling practice on phantoms and ultrasound scanning practice on models.

Trainees received the course well and felt it exceeded their RCoA learning outcomes. Their confidence in performing regional anaesthesia was significantly improved and commented the frequent sessions reinforced this compared to a one-off course. Figure 1 shows the summary of the feedback received:

We present a small group regional anaesthesia course, which revisits the core elements of performing nerve blocks. The aims of this course to improve needling and LA injection techniques and ultrasound scanning for nerve blocks were met. The feedback demonstrated that trainees preferred the spiral learning format to other regional anaesthesia courses and were able to independently perform blocks following attending to our course.

Due to Russia's full-scale invasion of Ukraine, the frequency of limb injuries in the overall statistics of military trauma is more than 40%. It is important to emphasize that today's reality has brought the relatively uncommon and poorly studied phantom pain to a new level of relevance and concern. 

Botulinum toxin therapy for phantom pain and pain in the stump Blocking of cholinergic transmission at the level of the neuromuscular synapse. As a result, the nerve endings at the synapse level do not respond to nerve impulses (chemical denervation) Injection of the drug under the navigation USD-control and EMG-control. Injection doses:150-250 units per limb divided into 4-5 injection points (neuromas, trigger points), subcutaneous injection. Frequency of injection: once in 3-4 months

Injection of botulinum toxin has been shown to be effective in the treatment of various types of neuropathic pain, including phantom pain after limb amputations, which is not treated with first-line drugs This treatment technique allows the patient to get rid of pain almost completely for a long period. From a personal perspective, the use of botulinum toxin has proven to be effective in 80% of the cases among 42 military amputees Pain reduction on the scale of VAS: from 8-9 points to 3-4 points Botulinum toxin is effective treatment for hyperhidrosis of the limb stump, which ultimately significantly expands rehabilitation opportunities

Botulinum toxin type A is a safe alternative to strong opioid therapy in cases of high-intensity PHP can significantly reduce the dose and duration of narcotic painkillers.

Shoulder surgeries are among the most painful surgical procedures in orthopedic practice.Interscalene brachial plexus block(ISB), although the most commonly utilized regional anesthesia technique for alleviating pain following shoulder surgery, may result in side effects such as hemidiaphragmatic paresis and Horner's syndrome.More distal blocks along the brachial plexus may provide postoperative analgesia while potentially having less effect on respiratory functions.The aim of this study was to determine whether there is a difference in postoperative pain scores between ISB and costaclavicular brachial plexus block(CCB).Secondary endpoints were adverse events and postoperative opioid consumption

Our study is a prospective observational study.Following ethical approval, a total of 62 patients undergoing for shoulder surgery under general anesthesia between 01.11.2022 and 01.11.2023 were included in the study after obtaining written informed consent.The local anesthetic agent(20mL of bupivacaine 0.25%) were identical for all study participants.A blinded investigator recorded pain scores at rest at 0.5,1,6,12,18 and 24 hours.Postoperative opioid consumption,time to first analgesic request and adverse effects were statistically compared

In both groups,VAS pain scores were similar at 0.5,1,2,3,6,12 and 24 hours(p>0.05).Postoperative opioid consumption was significantly lower in the ISB group compared to the CCB group.There was no significant difference between the time to first analgesic request and the need for rescue analgesia.The number of patients experiencing block-related complications(such as Horner's syndrome,hoarseness,dyspnea,etc.) was significantly higher in the ISB group compared to the CCB group(25%vs.0%;P<0.05)

In patients where preserving lung function is prioritized in relieving pain during shoulder surgery, CCB may useful analgesic alternative to ISB with fewer adverse complications

Prinzmetal angina is a know condition of intermittent segmental spasm in the coronary arteries causing transient ischemia resulting in angina and electrocardiographic ST elevation. Medical treatment includes both calcium channel blockers and nitrites. We present a case of a 49-year-old male with a 30-year history of Prinzmetal angina with failed medical management for possible thoracoscopic surgical cardiac sympathetic denervation. The patient was referred for a trial stellate ganglion block to temporarily inhibit the cardiac sympathetic chain.

A left stellate ganglion catheter was placed at anterior C 6 tubercle under ultrasound and fluoroscopic guidance. Contrast was injected into the catheter to confirm appropriate spread of contrast in the region of the stellate ganglion. ( Fig 1) A pulsed dose of 5 cc every 2 hours of 0.2 % ropivacaine was infused for 3 days. The patient had significant reduction of pain and incidence of his symptoms and elected for surgery. The patient underwent bilateral thoracoscopic sympathectomy for permanent treatment of his Prinzmetal angina. Of interest 5 cc of methylene blue dye was injected into the left sided catheter immediately prior to surgery and was seen in the right, and not the left chest. Fig2

The patient had significant reduction of the severity and incidence of his Prinzmetal angina. He has decreased his dose of nitrites and calcium channel blockers and is normotensive. Stellate ganglion catheters provide an extended trial of cardiac sympathectomy and may be helpful in predicting success of surgery.

Unicompartmental arthroplasty provides an alternative to total knee arthroplasty (TKA) for end-stage osteoarthritis (OA) affecting a single knee compartment, typically the medial compartment, and less commonly the lateral compartment. Patients undergo orthopaedic assessment for surgical suitability based on examination and X-ray findings of unicompartmental OA before surgical consideration. Sometimes, due to inconclusive X-ray findings or a long waiting time between initial X-ray findings and booking for surgery, the patient's knee OA can progress, and surgeons may opt for intraoperative conversion to TKA based on direct knee cartilage assessment. Can ultrasound effectively assess both knee compartments to confirm the diagnosis?

In this retrospective review of 35 patients scheduled for medial compartment knee arthroplasty, an ultrasound examination of the medial and lateral compartments and the posterior knee was conducted during genicular nerve and IPACK blocks. Findings in patients with advanced medial compartment arthritis (image1): 1.Bulging of the medial collateral ligament, 2.Bulging of the medial meniscus, 3.Osteophyte formation, 3-joint space narrowing, 4.Occasional joint effusions and Baker's cysts.

Similar ultrasound findings were observed in 7 out of 35 patients within the lateral compartment. These results were communicated to the surgeon. These findings were confirmed intraoperatively by direct assessment of the joint by the surgeon, ultimately leading to conversion to TKA for all eight patients.

In this retrospective review, point-of-care ultrasound was performed after spinal anaesthesia. A pre-anaesthetic ultrasound examination of the knee by the anaesthetist may confirm the diagnosis and allow adjustment of spinal anaesthesia dosage to accommodate surgical timing for unicompartmental versus TKA.

Severe postoperative pain due to tonsillectomy inhibits patients’ early oral intake and recovery after surgery. The maxillary and glossopharyngeal nerves doubly innervate the tonsils, and it is unclear which nerve is more involved in the pain. Although ultrasound-guided maxillary nerve block (MaxNB) has been administered to the dental surgery, the postoperative analgesic efficacy of MaxNB for tonsillectomy has not yet been studied in controlled trials.

This study was approved by the ethics committee of Sapporo Medical University Hospital (322-294). Forty-four patients aged 18 years or older undergoing tonsillectomy under general anaesthesia were randomly allocated to the block or placebo group. Both groups received ultrasound-guided bilateral MaxNB under general anaesthesia, with 5 mL of 0.375% ropivacaine per site in the block group and the same volume of saline in the placebo group. Patients were provided with intravenous fentanyl patient-controlled analgesia after surgery. The primary outcome was a visual analogue scale (VAS) pain score at rest at return to the ward, 2, 4, 8, and 24 hours after return.

One patient was excluded due to refusal to participate in the study. Twenty and 23 patients completed the study in the block and placebo groups, respectively. The VAS scores were not significantly different between the groups at any point during the 24 hours postoperatively. Median [IQR] cumulative fentanyl consumption was not significantly different (block: 50 [20-170] vs. placebo: 40 [0-140] μg/day, p=0.62).

MaxNB for adult patients undergoing tonsillectomy did not decrease VAS scores and fentanyl consumption for 24 hours postoperatively compared to placebo.

Postoperative pain is a common concern associated with total hip arthroplasty (THA). We hypothesised that the concurrent administration of pericapsular (PENG) and parasacral (PS) sciatic block will result in superior postoperative analgesia in individuals undergoing THA. Our primary objective was to compare 24-hour opioid consumption. Secondary outcomes included 48-hour opioid consumption, Numerical Rating Scale (NRS) muscle strength (hip adductors, plantar flexors and quadriceps) and any adverse effect.

Sixty 18 to 75 years old American Society of Anaesthesiologist (ASA) class I and II undergoing THR under general anaesthesia were randomised to receive: 20 mL of 0.2 percent ropivacaine in PENG block (Group P) or PENG and PS sciatic block (20 ml of 0.2%) in Group PS. Pain scores and muscle power (quadriceps, hip adductors and plantar flexors) were measured at 1,4,8,12,24 and 48 hours. Fentanyl consumption was measured at 24 and 48 hours post-operatively.

The mean 24 and 48-h fentanyl consumption was statistically more in Group P. Resting and Dynamic NRS scores were lesser in Group PS at all time intervals. Quadriceps muscle power at different time intervals reveal no statistically significant difference. Plantar flexor strength was more in Group P at 1 hour and 4 hour while hip adductor strength was more at 1 hour.

Adding a PS sciatic nerve block to PENG block increases its analgesic efficacy with decrease in muscle power at 1 and 4 hours. Further randomised trials are needed to confirm our findings.

Cervical plexus block (CPB) is a an effective block for providing anaesthesia for head and neck region. Intermediate CPB involves drug deposition deep to investing layer of deep cervical fascia and has shown to provide similar efficacy to deep CPB. We anticipate that higher volume of drug will result in spread beyond the prevertebral fascia and blockade of phrenic nerve. The aim of this cadaveric study is to evaluate and compare the drug spread in intermediate CPB using two different volumes – 10 or 20 ml.

Ultrasound guided intermediate CPB was given with either 10 or 20 ml of methylene blue on 4 fresh soft embalmed cadavers bilaterally at the level of C4. Anatomical dissection was performed to look for dye spread to cervical plexus, brachial plexus, phrenic nerve, carotid sheath and deep cervical nerve roots.

Branches of cervical plexus were stained in all the blocks. Higher volume of drug resulted in deep staining of phrenic nerve and upper trunk of brachial plexus. Carotid sheath and vagus nerve was also involved in 2/4 (50%) of CPB with 20 ml. With 10 ml of injectate volume, phrenic nerve was lightly stained in 3/4 (75%) of the blocks. Cervical nerve roots were not stained in any of the blocks.

Both low and high volume result in consistent spread to superficial cervical plexus branches. These findings support use of 10 ml of drug in intermediate CPB for providing analgesia for neck surgeries with possible sparing of phrenic nerve and brachial plexus function.

Regional anaesthesia offers several advantages including early recovery and early discharge. The incidence of long-term complications with Peripheral Nerve blocks (PNB)is 0.02%.Follow up is important to understand the local incidence rate, for early detection and timely intervention of treatable cause and improving patient trust and assurance.We aimed to evaluate our follow up practice and further improve it .

We are a specialist orthopaedic centre performing more than 2000 PNBs in a year. Patient records were reviewed retrospectively over two weeks. Follow up pathway was determined depending on patient’s post operative destination of either discharged home or to the inpatient ward.Telephonic follow up for day case patients and a baseline survey for junior doctors/ nurses in the ward was done to evaluate our practice.

101 peripheral nerve blocks were performed on 76 patients in two weeks .17% of these patients were discharged home the same day. Less than 30 % of these patients had a follow up before discharge. While 63% received verbal aftercare instructions, only 27% received written instructions. For inpatients, 35 junior doctors and nurses were surveyed. While 45 % reported documenting about limb observations post block, only 37% routinely advised about post nerve block limb precautions .

Limited Follow up,deficiency in aftercare instructions and knowledge of junior doctors/ nurses has been recognised. We recommend written instructions should be provided to all day cases and regular teaching sessions for junior doctors/nurses. Further improvement with development of a local patient care pathway and possibly exploring digital based F/U in future.

Background and aims Transcutaneous electrical nerve stimulation (TENS) is an established technique for pain management. There is evidence that stimulation delivered through a dome-shaped electrode is associated with improved clinical outcomes compared with conventional flat patch electrodes currently utilized in TENS, due to a greater depth and area of electrical stimulation. The aim was to investigate this using computational modelling analysis

Methods A 3D finite element model of cutaneous tissue coupled with an active model of nerve fiber was developed, for simulation of E-fields originating from various electrode geometries and stimulation configurations. Outputs from the tissue model were transferred into the nerve model to determine the minimum currents required to activate cutaneous fibers. The efficacy was based on the level of activation of Aβ, Aδ and C fibers.

Results Dome-shaped electrodes required significantly lower device current to activate nerve fibers compared with flat TENS electrodes. The depth of electrical stimulus was 4x greater and the area of field activation 40% greater. The maximum amplitude was 40x higher with the dome shaped electrode compared to TENS electrodes at depths < 2 cm. The dome-shaped electrode could activate large nerves at up to ~1 cm depth with current < 30 mA, whilst TENS could only do so at < 0.25 cm.

Conclusion A dome-shaped electrode appears to recruit more nerves at the same level of stimulating current due to its greater depth of penetration and activation field compared with conventional TENS. This may equate with improved pain and functional outcomes for patients.

Cleft lip and palate (CLP) is a common congenital abnormality necessitating early surgical intervention. Palatoplasty, aimed at restoring normal anatomy, poses postoperative challenges including pain and complications. Traditional pain management with opioids and NSAIDs presents risks, prompting exploration of regional nerve blocks. This study compares the efficacy of sphenopalatine ganglion block (SPGB) and palatal block for postoperative analgesia in children with cleft palate undergoing palatoplasty. The aim is to compare SPGB and palatal block efficacy on postop- analgesia .Primary objectives include assessing postoperative analgesia using FLACC score. Secondary objectives was to evaluate need of rescue analgesia need and parental satisfaction.

This is prospective randomized controlled study . A sample size of 50 (25 per group) was calculated. Children aged 1-5 years with cleft palate meeting inclusion criteria were randomized into two groups: palatal block (Group A) and SPGB (Group B). Both blocks were given after administration of general anaesthesia. Postoperative analgesia was assessed using FLACC score and parental satisfaction was assessed using Likert scale.

Result shows postoperative pain using the FLACC scale scores were lower significantly in Group B at various time points (0, 3, 6, 9, and 12 hours post-operatively) compared to Group A (p<0.001 ). Group B requiring significantly less rescue analgesia compared to Group A(p=0.001). Parental satisfaction, assessed on a Likert scale, was significantly higher in Group B compared to Group A (p=0.004).

Regarding optimal pain management strategies for children undergoing palatoplasty sphenopalatine ganglion block provide better postoperative analgesia along with parental satisfaction than palatal block.

Effective blinding in clinical trials is crucial to avoid bias. We collected secondary data to assess the adequacy of investigators' blinding to study drugs during five prospective randomised, double-blind studies to estimate optimal local anaesthetic doses for axillary, interscalene and supraclavicular brachial plexus blocks (BPB).

Following an ethics committee-approved study protocol, an investigator divided a local anaesthetic's study dose into four or six 10 mL syringes, covering their barrels entirely with an opaque tape. An expert anaesthetist performed the required ultrasound-guided BPB using these syringes. We asked this anaesthetist to guess the drug volume used at the end of the injection. Importantly, we did not inform them of the accuracy of their guess and chose patients randomly. We recorded this data and analysed it using SPSS 29.

We collected data for 20 out of 81 axillary blocks, 11 out of 46 interscalene blocks, and 22 out of 73 supraclavicular blocks. The error in the guesses ranged from -55% (underestimate) to 100% (overestimate), and the median of errors was –11%. Figure 3 shows the variability in the guess accuracy at different local anaesthetic volumes.

We demonstrate that robust blinding of drug syringes is possible using a simple method of carefully placing opaque tape covering their barrels entirely. The blinded investigators cannot correctly guess the volume of a drug injected, e.g., by looking at the position of the syringe plunger or the ultrasound machine’s screen, preserving the data integrity. Reference: Day SJ, Altman DG. Blinding in clinical trials and other studies. BMJ.2000;321(7259).

Severe pain is a prevalent problems associated with advanced oncological disease. Interventional pain management as nerve blocks, neurolysis, or placement of epidural and peripheral catheters with drug infusions has been shown to improve pain control and decrease the need for systemic opioids. Intrathecal neurolysis is a chemical destruction of the nerves; it aims to provide analgesia by administration of neurolytic substances in the subarachnoid space.

A 47-year-old female patient with a history of a metastatic colorectal adenocarcinoma, with rapid and progressive advance of the disease; therefore, she received multiple therapeutic and interventional options to relieve pain, was refractory to different drug combinations and interventions, at fisical exam she had advanced terminal disease with motor involvement in the lower limbs secondary to tumor infiltration, with a muscle strength of 2/5 in the left lower limb and 3/5 in the right lower limb, had a derivative colostomy and urinary catheter

By prone midline approach, the L5–S1 intervertebral level was located in an AP view, a needle was inserted into the subarachnoid space, was confirmed with contrast medium, and return of cerebrospinal fluid (CSF) was observed, 2 ml of 96% absolute alcohol was injected very slowly, and the patient was kept in the prone position for 30 min. The procedure was performed without complications.

This is an accessible and cost-effective procedure, its use should be encouraged, since it could be a helpful alternative for the management of patients with refractory pain in the terminal stage.

The appearance of sudden intense pain, after a peripheral nerve block ceases, is kown as Rebound Pain (RP). The reported frequency is described as between 40-60%. To reduce its occurrence, the use of adjuvants and the use of perineural catheter have been described. Dexamethasone, both perineural and also intravenously, reduces the incidence of RP. The risk decreases to approximately 10-20%. The methodology of studies using continuous technique has not allowed us to further clarify the benefit of their use. Our objective was to measure the incidence of RP in patients undergoing shoulder rotator cuff surgery with the use of home perineural catheters in our postoperative ambulatory REDCAP registry.

The study has ethics committee approval. A review of REDCAP was carried out from January 1, 2020 to December 31, 2023, extracting data from patients with a diagnosis of rotator cuff tear. Pain >7 on a scale of 0-10 was considered rebound pain.

495 patients were identified. 58 were lost to post-discharge follow-up (11.7%). Among the remaining 437 patients, 81 (18.5%) reported pain >7 at least once. On first postoperative day, 26 (5.7%). On 2nd postoperative day, 33 patients (7,8%) At the end of the infusion, 5,8 % of patients reported rebound pain according to the work definition.

These results are lower (not staistacally comparable) than those described with a single injection after 24 hours with or without adjuvants. It is interesting to know that the phenomenon can also occur after 48 and a60 hours when the blockade ends.

To compare the effect of ultrasound-guided PENG block vs ESPB on pain scores, opioid requirements, and stress response to surgery expressed by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in children scheduled for hip surgery.

90 patients aged 2-7 years, ASA PS I-III were randomised into 3 equal groups, each receiving a PENG block, ESPB, or control group (CG). In all groups, sedation was performed with continuous propofol infusion at 5mg/kg/h. Spontaneous ventilation was maintained with an oxygen mask at 2 L/min. Spinal anaesthesia was performed with 0.1ml/kg of 0.5% ropivacaine. After the spinal anaesthesia, the block was performed with 0.5/kg mL of 0.2% ropivacaine. The primary outcome was the pain scores (FLACC). The secondary outcomes included postoperative NLR, PLR, and cumulative opioid consumption.

The FLACC score was significantly lower in the ESPB and PENG groups compared to the CG (p<0.0001), as seen in Table 2. The NLR and PLR levels were significantly lower in the PENG and ESPB groups (p<0.0001) compared to the CG. There was no difference in NLR and PLR levels between the PENG and ESPB groups. The cumulative opioid consumption was significantly lower in the PENG and ESPB groups compared to the CG (p<0.0001). Also, 43% of children in the PENG group and 50% of children in the ESPB group did not require opioids postoperatively, as seen in Table 3.

PENG block and ESPB provide better analgesia, lower opioid consumption and lower NRL and PLR levels after hip surgery.

This study determined whether scalp nerve block (SNB) could reduce the incidence of postoperative symptomatic cerebral hyperperfusion syndrome (SCHS) in adult patients who underwent after superficial temporal artery (STA)–middle cerebral artery (MCA) anastomosis for moyamoya disease (MMD).

Patients undergoing STA-MCA anastomosis for MMD were retrospectively divided into SNB (n = 167) and control (n = 221) groups depending on whether SNB was performed at the end of surgery. Inverse probability of treatment weighting was used to balance the two groups. The primary outcome measure was the incidence of postoperative SCHS.

The incidence of postoperative SCHS was not different between the SNB and control groups (62 [37.1%] vs 100 [45.2%], P = 0.133), but its duration was shorter in the SNB group (3 [2–6] vs 5 [3–7] d, P = 0.014). The SNB group had lower pain scores (postoperative day [POD] 0: 2 [1–3] vs 3 [1–4], P = 0.004; POD 1: 2 [1–2] vs 2 [1–3] d, P = 0.039) and systolic blood pressures (POD 0: 129 [121–137] vs 139 [130–149] mmHg, P < 0.001; POD 1: 125 [117–136] vs 131 [124–139] mmHg, P < 0.001) and shorter lengths of intensive care unit (1 [1–2] vs 2 [1–2] d, P < 0.001) and hospital (10 [9–13] vs 10 [8–14] d, P = 0.044) stays.

Despite some benefits, SNB did not reduce the incidence of SCHS after STA–MCA anastomosis for MMD.

Located in a non-trauma centre, our department grapples with logistical hurdles in providing comprehensive care for rib fracture patients. Recognising this challenge, we endeavour to establish a consistent and dedicated anaesthetics service to optimise patient management. This study aims to evaluate the demographic profile of our patient population and assess the impact of chest wall blocks, seeking evidence to support our initiative.

A random retrospective review of 30 rib fracture patients referred to our pain team between October 2023 and April 2024, identified through the pain team register, was conducted. Data encompassing demographics, medical history, and outcomes were collated. Erector Spinae or Serratus Anterior blocks were administered to 14 patients, while the others received standard treatment. Detailed results are delineated in Table 1.

Although the two groups had comparable age and STUMBL scores, the patients who received blocks exhibited more respiratory comorbidities. Nevertheless, outcomes, inclusive of hospital stay length and ICU admissions, demonstrated parity between groups. No fatalities were recorded.

Our analysis underscores the potential benefits of providing chest wall blocks in rib fracture patients, particularly those with concomitant respiratory comorbidities. We advocate for the establishment of a dedicated anaesthetics service, supported by our local safety protocol and ongoing training initiatives for practitioners. This strategic approach aims to refine analgesic care and enhance patient outcomes within this vulnerable demographic, aligning with our commitment to comprehensive and consistent patient-centred care.

The use of adductor canal block (ACB) for post endoscopic knee surgery (EKS) analgesia is a widely accepted technique. This study was conducted to assess the efficacy of combining ACB with anterior cutaneous femoral nerve block (ACFB) against ACB alone in EKS.

A single blind randomized observational study of 35 patients in each group of ACB only (Gr-A) and ACB with ACFB (Gr-B). Both Gr-A and Gr-B received 25 ml of 0.2% ropivacaine with additional 3-5 ml for intermediate and medial femoral cutaneous nerve block (ACFB) in Gr-B. Both groups received routine paracetamol and rescue analgesia was maintained by PCA morphine. All patients were operated under spinal anesthesia. 24 hours data collected for vitals, duration of analgesia, morphine consumption and complications.

Demographically and hemodynamically all the groups were not significantly different, but Gr-B showed lower morphine consumption (5.5 ± 0.4) mg than Gr-A (7.4 ± 0.6) mg (p < 0.05) and longer duration of analgesia (6.7 ± 0.2) hour for Gr-B and (6.1 ± 0.3) for Gr-A, (p < 0.01). No significant complications observed in either group.

Addition of femoral sensory cutaneous blocks provide better analgesia and duration than adductor canal saphenous block alone in endoscopic knee surgery.

Use of epidural opioids is a standard practice nowadays, not only for pain management during surgery but also in the postoperative period. It is well known that hydrophobic drugs distribute better to hydrophobic tissues such as fat located nearby epidural space instead of spreading to the cerebrospinal fluid, as is the case with fentanyl. Regarding morphine, it has been demonstrated that it is better used for spinal administration, whereas other opioids are more likely to be administered at the epidural space.

In this case report, we present an 81-year-old male patient who underwent a pancreatectomy, splenectomy and partial gastrectomy by laparotomy. Prior to surgery, thoracic epidural technique was performed, the catheter placement was checked by epidural test dose and a single bolus of morphine 2 mg, dexamethasone 4 mg and ropivacaine 0.2% 3 ml was administered.

During the procedure, we used NOL (Nociception Level Index, Medasense) to monitor the effectiveness in which it was observed that no extra analgesia was needed during the surgery with <25 NOL value in 96% of the surgical time. In the postoperative period, patient controlled analgesia was used to determine if any extra analgesia was required after the initial bolus. No pain was referred by visual analog scale until 30 hours after surgery. No postoperative complications related with the use of opioids were found.

This case report argues for the need of more studies about epidural analgesia by single bolus with morphine, dexamethasone and local anesthetics and clinical relevance for patients undergoing laparotomy.

Upper extremity surgical procedures distal to the elbow can be performed under axillary brachial plexus block. Using ultrasonography, the block can be executed in two ways – perineural (PN) and perivascular (PV). A prospective, trust-based clinical audit was designed to observe and compare these two methods. The primary outcome of the study was the time to perform the nerve block, which was defined as the time from probe placement to withdrawal of needle. The secondary outcomes were the block success rate, incidence of any complications, and onset of sensory and motor anaesthesia in the respective nerve divisions.

Findings were compared in 50 patients scheduled to undergo orthopedic surgeries distal to the elbow, under axillary brachial plexus block only In PN group, local anaesthetic was deposited individually around four nerves. In PV technique, a single injection of local anaesthetic was performed at 6 ‘o’ clock position with respect to the axillary artery, with the aim to surround the artery with drug.

PV group had a shorter procedural time of 7.64 minutes, whereas the PN group had a mean time of 10.56 minutes. PN group took longer to achieve motor anaesthesia (19.52 minutes). A higher rate of successful block was observed in the PV group (92 %) than the PN group(84%). One vascular puncture was observed in PV group.

PV technique can be used with a higher success rate in large volume centres due to shorter performance times, especially in population with complex anatomy where identification of all four nerves is difficult.

Fast track surgery involves optimization intra-operative anesthesia management, postoperative pain and any side effects with the goal of reducing hospitalization. Multimodal analgesia engages loco-regional anesthesia and opioid sparing theory supporting fast track surgery.

It is a retrospective observational cohort study conduct at “Santa Maria della Misericordia” Hospital in Udine. Our primary aims was to compare the post-operative analgesia provided by TAP block versus spinal anesthesia (SA) in conjunction with general anesthesia (GA) for elective LPS hysterectomy from March to June 2023. Our secondary aims were to compare prevalence of postoperative side effects.

among 47 patients treated with LPS hysterectomy, 23 received SA and 24 TAP block. Population and surgical characteristics were comparable. The overall pain intensity score (NRS) is significantly reduced at 6h (0 vs 0.5, p 0.004) and 12h (0 vs 0.5, p 0.006) in the SA group compared with TAP block group. Equally SA group received less fentanyl IV intraoperatively (258 mcg vs 339 mcg, p 0.002), a lower cumulative dosage of ketorolac (150 mg vs 180 mg, p 0.044) and acetaminophen (4 g vs 5 g, p 0.001) at 48h. The incidence of PONV is higher in SA group (45.8% vs 13 %, p 0.024) without impact on the length of hospitalization.

Pts undergoing LPS hysterectomy have excellent pain control with both analgesic techniques, making them suitable in the fast-track gynecologic surgery setting. It will be necessary to review more data to reduce the incidence of PONV.

Introduction Our objective was to examine departmental practices regarding perioperative epidural placement in the Mater Hospital over a 4-year period.

Methods Our anaesthesia information management database was queried to retrieve details of perioperative epidural placement from 2017 to 2020. Data captured included patient position, loss of resistance (LOR) technique, complications and documentation quality.

Results 1072 epidurals were placed in the study period. Epidural use declined from 309 in 2017 to 210 in 2020. There was a large decrease in epidural placement for Thoracic and Urology surgery while epidurals for Gynaecological surgery increased. In the same period there was also a large decline in abdominal blocks and an increase in thoracic blocks performed. The large majority of epidurals were sited in the sitting position using a midline approach. LOR to saline versus air was similar. Median procedure time was 25 minutes. Accidental dural puncture (ADP) rate was 2.1% (23/1072), however only 2 patients required an epidural blood patch.

Epidural use for Urology and Thoracic surgery has declined, likely secondary to greater use of laparoscopic/robotic techniques. There may be a resulting overall decline in epidural numbers although the impact of Covid-19 in 2020 prevents us from drawing definitive conclusions. The majority of clinicians adopt similar technical approaches to placement. ADP rate is similar to previously published rates and requirement for blood patching is reassuringly low.

A posterior pericapsular deep-gluteal block (PPD) is a regional approach aiming to anaesthetize the sensory fibres originating from the sacral plexus. Branches of the sciatic nerve, gluteal nerves and the nerve to the quadratus femoris muscle (NQF) provide sensory innervation of the posterior hip capsule and are therefore the main targets of a PPD. However, further experimental validation of a PPD is needed. In this study, we describe the spread of dye in the posterior hip region after PPD injection in a body donor, focusing on the NQF.

Two male, unembalmed bodies were obtained from the human body donation program of the university and included in the study. Using ultrasound guidance, a PPD (Vermeylen et al.) was performed injecting 5 ml, 10 ml, 15 ml or 20 ml of dye using a custom-made mixture (10% latex, 1.5% methylene blue 10 mg/ml and 88.5% water) in the targeted area. Each of the four posterior hip regions were dissected and dimensions of the spread were obtained.

Despite consistent coverage of the posterior hip joint area, none of the hip regions showed staining of the NQF after PPD injection. Inconsistent injections, too low volumes of dye and post-mortem disruption of tissue integrity are possible explanations for the inadequate spread towards the target nerve.

In this study, we could not demonstrate an adequate spread to the NQF using a PPD injection of dye in the posterior hip region. We conclude that the effectiveness of the PPD block requires further anatomical and clinical validation .

ERAS Society recommends intrathecal opiates and continuous local anaesthetic wound infusion for post-operative analgesia following liver resection. However, patients with contraindications to central neuraxial block may receive suboptimal analgesia. Emerging evidence suggests that erector spinae plane block (ESPB) may be a promising alternative, but a systematic review has not been available thus far. This systematic review and meta-analysis aims to compare the analgesic efficacy and safety of single or continuous ESPB with any other peripheral regional anaesthetic (RA) technique or with no block in adults for liver resection under general anaesthesia.

This review was undertaken according to a prospectively registered protocol on PROSPERO website under the registration number CRD42023445867. It follows the guidance on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The literature search included PubMed, Embase, Web of Science Citation Index, Europe PMC and Cochrane Central Register of Controlled Trials until 17th July 2023. The primary outcomes of this review were 24-hour postoperative pain score at rest and ESPB-related complications.

Eleven randomized controlled trials with a total of 629 participants were included in the systematic review and meta-analysis. At 24-hour after liver resection, ESPB provided better analgesia compared to no block or other peripheral regional block, while analgesic effect was inferior to intrathecal morphine (ITM). ESPB reduced opioid consumption and its related complications. No ESPB procedure-related complications were reported.

ESPB provides effective pain control after liver resection where ITM is not an option. It has a high safety margin and reduces opioid-related complications.

Anesthesia is known to diminish FRC,leading to atelectasis and compromised gas exchange.PEEP administration has been observed to enhance FRC optimization.PSV is known for its potential to improve gas exchange during GA.However, there is a scarcity of data regarding the ideal PEEP and PS levels for children undergoing GA with LMA for minor outpatient surgeries. This study aimed to assess the impact of inspiratory PS levels on the prevention of atelectasis following induction of anesthesia and residual atelectasis in the early postoperative phase using LUS,as well as,to evaluate the influence of this pressure support on ventilation parameters in pediatric patients undergoing GA with a LMA for minor and outpatient surgery.

A randomized double-blinded CT was conducted on ASA I-II pediatric patients scheduled for minor outpatient surgery under GA and locoregional anesthesia.Ventilation parameters such as ETCO2,tidal volume,and respiratory rate were evaluated and compared between two groups at three phases during the procedure.

Significant differences were observed in lung aeration scores based on LUS between the PSV group and the SV group,with higher scores in the SV group.ETCO2 levels were significantly higher in the SV group,while tidal volume was significantly lower and respiratory rate was significantly higher in the SV group compared to the PSV group.No significant difference was noted in saturation levels between the two groups.

PSV has been shown to enhance ventilation parameters and mitigate the occurrence of post-induction and residual atelectasis in the immediate postoperative phase among children undergoing GA with mechanical ventilation utilizing a LMA for minor outpatient surgeries.

Recent studies suggest a possible antinociceptive effect of esmolol. The aim of this study is to investigate the effect of an infusion of esmolol on intraoperative nociception, as well as on postoperative acute and chronic pain.

In this interim analysis, 35 patients scheduled for inguinal hernia repair were randomized with identical blinded syringes to either the esmolol group, receiving a loading dose of 0.5 mg/kg of esmolol and maintenance dose of 50 mcg/Kg/min or to the placebo group, receiving saline. Intraoperative nociception as assessed by the percentage of anesthesia time during which NOL was<25 as well as postoperative acute and chronic pain with NRS and DN4 scores were analyzed.

Intraoperatively, the percentage of time NOL was<25 was higher in the esmolol group versus the control group (p=0.007). The esmolol group demonstrated lower NRS scores on arrival to PACU than the control group at rest and during movement (p 0.019 and 0.015 respectively) and lower NRS scores at discharge from PACU than the control group at rest and during movement (p 0.037 and 0.014 respectively). More patients required additional analgesia in PACU in the control group versus the esmolol group (p=0.01). Cumulative morphine consumption in the PACU was lower in the esmolol group versus the control group (p=0.004). No effect of esmolol on chronic neuropathic pain was demonstrated.

Intraoperative esmolol administration seems to decrease intraoperative nociception and to affect aspects of postoperative recovery by mitigating early postoperative pain levels and decreasing the need for opioid rescue medication following inguinal hernia repair.

Laparoscopic antireflux fundoplication,despite being less invasive surgery,require adequate postoperative analgesia.Sub-anesthetic dose of ketamine have proven efficacy for reducing pain scores as well as reducing postoperative opioid consumption in a wide variety of surgical procedures.

This is a prospective randomized controlled study enrolling 64 patients aged over 18 years who underwent laparoscopic antireflux fundoplication.Before scin incision, in Ketamine group,0,4 mg/kg of Ketamine was injected as a bolus followed by a 0,25mg/kg/h Ketamine infusion continued till the scin was closed.Control group received normal saline.The visual analogue scale (VAS) of 0-10, was used to measure each patients level of pain an 1, 2, 6, 12, 24, 36 and 48h after surgery.Total postoperative tramadol consumption, time of the first dose,hospital length of stay,side effects and presence of nausea and consumption of metoclopramide on the first postoperative day were recorded.

The total intraoperative opioid (Fentanil) consumption,extubation time,hospital length of stay, and presence of nausea and consumption of metoclopramide have significant difference between the groups.The present study showed that there were significant differences between groups in terms of VAS at 1h, 2h. 6h. 12h, 24h, 36h and 48h (p<0.001).The total postoperative consumption of Tramadol was lower in the Ketamine group, and the time of the first administration of the drug was longer, but without statistical significance between the groups.There was no reported side effects in either group.

In laparoscopic antireflux surgery,intraoperative Ketamine infusion at sub-anesthetic doses could be an effective and safe technique for reducing postoperative pain,hospital length of stay and presence of nausea.

Programmed intermittent epidural bolus (PIEB) has shown to reduce local anesthetic consumption compared to continuous epidural infusion (CEI) during labor analgesia. This study aimed to compare the efficacy of PIEB versus CEI in thoracic epidural analgesia (TEA) for providing postoperative pain control after open upper abdominal surgery.

After receiving ethics committee approval, 120 adults who underwent open upper abdominal surgery were randomly allocated to receive epidural solution either as PIEB(4ml/40min) or as CEI(6ml/h) via thoracic epidural catheter for 60h postoperatively. Patient-controlled epidural analgesia (PCEA) for additional boluses as needed was standardized across both groups. The primary outcome was 24-hour epidural drug consumption. Secondary outcomes included epidural drug consumption on postoperative hour 24-60h, time to first PCEA demand, pain scores, rescue analgesics, side effects, recovery, and satisfaction.

The PIEB group demonstrated a significant reduction in mean 24-hour epidural drug consumption compared to the CEI group (173.46±32ml vs 200.75±46ml, respectively; mean difference -27.29ml; 95%CI -39.74 to -14.84; P<0.001). Additionally, the median time to first PCEA demand was significantly longer in the PIEB group (188 minutes, IQR 30-778) versus the CEI group (44 minutes, IQR 21-120) (P=0.002). There were no significant differences between the groups in terms of pain scores, rescue analgesic consumption, side effects, recovery outcomes, or patient satisfaction.

PIEB reduced epidural drug consumption in the first 24-hour after open upper abdominal surgery compared to CEI, suggesting PIEB may provide more efficacy in early postoperative period. Further research is needed to assess the optimal regimen of epidural drug delivery in TEA.

It was found that inhibition of xanthine oxidase are accompanied by anti-ischemic and neuroprotective effects in the experiment and clinic.

The study of cerebral ischemia in the experiment was carried out on 4 groups of outbred rats: I- sham-operated - control, II- ligation of the left carotid artery without additional intervention, III- administration of allopurinol before ligation of the carotid artery, IV- ligation of the carotid artery + administration of allopurinol 1 hour after surgery.

In a histological examination of brain preparations made in the frontal plane at the level of the mid-central part, covering both cortical and other structures, 5 μm thick, stained with hematoxylin-eosin, in animals of group I the following morphological picture was observed: there were no significant differences in both halves of the brain. In rats of group II, zones of damage to the nervous tissue were found in the cortex on the side of occlusion. No clear architectural division into cortical plates was recorded. In group IV, the changes were identical to group II. When studying brain slices in rats of group III, the degree of alterative disorders was less pronounced compared to groups II and IV. This was expressed both in a smaller area of damaged areas and in a relatively smaller number of cortical cells subjected to deep degeneration, meaning pyknotically wrinkled with eosinophilic cytoplasm. In addition, none of the animals in this group had perivascular hemorrhages or leukodiapedesis.

Preliminary inhibition of xanthine oxidase before modeling experimental ischemia, has neuroprotective effects.

Peer-review represents a cornerstone of the scientific process, yet few studies have evaluated its effectiveness to predict scientific impact. The objective of this study is to assess the effectiveness of peer-review on measures of impact for manuscripts submitted for publication.

We analyzed all submitted manuscripts with abstracts (3,327) to Regional Anesthesia & Pain Medicine (RAPM) between August 2018 and October 2021. Initially, we categorized each article by topic, type, acceptance status, author demographics, and open-access status via a double-review process. Articles were scored based on the initial peer review recommendation. With any reviewer from RAPM designating the “reject” classification, we further investigated if the article was published in any indexed journal comparing total citations. The primary outcome was measured via the number of citations each article had on ClarivateTM within the last two years; the number of citations from Google Scholar was also collected, along with the Altmetric score.

Out of 424 articles that met our inclusion criteria for analysis, we found no significant correlation between the number of Clarivate 2-year review citations and reviewer rating score (r=0.042, p=0.47), Google Scholar citations (p=0.42) or Altmetrics (p=0.70). There was no significant difference in two-year Clarivate citations between accepted (mean 7.48, SD 8.80) and rejected manuscripts (mean 5.51, SD 5.02; p=0.39). Altmetric score was significantly higher for RAPM-published papers compared to RAPM-rejected ones (mean 24.04, 63.93 vs. 2.55, 4.96; p<0.001).

The ratings from peer review did not correlate with citation counts, leaving uncertain their influence on quality and other measures.

This prospective, randomized, observer-blinded trial aimed to compare the efficacy of ultrasound-guided proximal and distal intercostobrachial nerve block (ICBNB) as adjuncts to supraclavicular brachial plexus block (SC-BPB) for upper arm arteriovenous access procedures. We hypothesized that the proximal approach would achieve higher success rates than the distal approach.

Sixty end-stage renal disease patients undergoing upper arm arteriovenous access surgery were randomly assigned to receive either proximal (n=30) or distal (n=30) ICBNB. Both groups received a 10-mL mixture of 0.25% levobupivacaine-1% lidocaine with epinephrine 2.5 μg/mL. A blinded observer recorded successful ICBNB (primary endpoint), defined as sensory blockade at the medial upper arm and axilla. Imaging, needling times, and block-related complications were recorded. Subsequently, SC-BPB with 30 mL of local anesthetic was performed in both groups. Surgical anesthesia, postoperative pain scores, intravenous tramadol requirement, and sensory blockade duration were also recorded.

The proximal group had a higher percentage of sensory blockade at the axilla (97% vs 73%, P=0.026) but comparable blockade at the medial upper arm (97% vs 97%, P=1.000). Ultrasound image acquisition was faster with the proximal approach (13.4 [10.0-18.3] vs 18.8 [14.0-26.5] seconds, P=0.015). No differences were observed in needling time, ICBNB onset time, block-related complications, surgical anesthesia, or postoperative outcomes.

Proximal ICBNB consistently reduced sensation at the medial upper arm and axilla, while one-fourth of distal blocks spared the axillary area. Both approaches, combined with SC-BPB, effectively facilitated upper arm arteriovenous access procedures; however, proximal ICBNB might be preferable for axillary surgery.

Ultrasound-guided Pericapsular Nerve Group (PENG) block is an emerging regional anesthesia technique for patients undergoing hip surgeries. PENG blocks target the articular sensory branches of the hip capsule and it is thought to spare the motor branches. This review evaluates the analgesic efficacy and effectiveness of PENG block in patients undergoing hip surgeries.

We conducted a meta-analysis of randomized controlled trials (RCTs) in patients undergoing hip surgeries where PENG block was compared to no block, placebo, or other analgesic techniques. Our primary outcome is the postoperative opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, sensory motor assessment, quadriceps weakness, incidence of postoperative falls, first analgesic request, PACU and hospital length of stay, functional outcomes, and persistent post-surgical pain.

We analyzed 24 RCTS with a total of 1474 patients. There is moderate quality of evidence to suggest that PENG block decreased 24 hour morphine consumption by a mean difference (MD) of 2.54mg (95% CI: -3.69, -1.40). The greatest difference was found when PENG block was compared to sham/no block. However, after adjusting for publication bias, the MD decreased to 1.05mg (95%CI: -2.25, 0.15).

Our meta-analysis regarding the use of PENG block for analgesia in hip surgeries suggests that there was minimal difference with no clinical significance in the first 24 hours after hip surgery but the reduction of morphine milliequivalent was seen more in total hip arthroplasty cohorts than in hip fracture patients.

In elderly patients undergoing surgery frailty can lead to adverse perioperative outcomes. The present study aimed to evaluate the diagnostic accuracy of ultrasound (USG) measurements of rectus femoris (RF) and quadricep muscle in discriminating frailty in elderly patients and to assess their predictive ability for perioperative outcomes

In this prospective observational study, we enrolled 87 elderly patients who were scheduled to undergo elective surgeries under anaesthesia. In the preoperative period, frailty was assessed by the Clinical Frailty Score. Preoperative USG measurements of the RF and quadricep muscles were obtained. These measurements were standardized for different body habitus and gender. Patients were followed up to 30 days after surgery and the perioperative clinical outcomes such as the occurrence of complications, intensive care admission, and mortality were noted.

A total of 87 patients were enrolled for participation in the present study out of which 6 were lost to follow-up. Using the Clinical Frailty Scale (CFS), we found that out of 81 patients, 28 were non-frail and 53 patients were frail. There was a statistically significant difference in the USG parameters between frail and non-frail patients. We found that USG parameters have good diagnostic ability for frailty (AUC=0.7) and when these were adjusted for the body surface area their diagnostic ability increased (AUC=0.8). However, the USG parameters have fair accuracy for predicting postoperative clinical outcomes ( AUC 0.6 to 0.7).

USG measurement of thigh muscles in preoperative patients may be used as a marker for frailty to predict their clinical outcomes after surgery

Postoperative pain after orthopedic surgery is severe and prolonged. Persistent severe postoperative pain in the first 24 hours is a significant factor in the chronicization of pain. The treatment should be early, multimodal, and aimed at antinociceptive, anti-inflammatory, and antihyperalgesic effects. Several studies have reported that preoperative use of gabapentinoids primarily reduces initial postoperative pain and spares the use of opioids. We conducted a prospective, randomized, single- blind study to evaluate the effect of this molecule in reducing postoperative pain and overall analgesic consumption, particularly morphine.

Sixty patients aged between 20 and 75 years, scheduled for non-urgent orthopedic surgery under spinal anesthesia and classified as ASA I/II, were randomized into two groups: G1 and G2 (receiving 75 mg of pregabalin orally 2 hours before the surgery).We evaluated intraoperative hemodynamic parameters, patient anxiety at arrival and departure from the operating room, postoperative pain using the visual analog scale

The demographic characteristics of our population were comparable between the two groups, as was the surgical indication. There was a significant difference in pain evaluation scores at H6 and H24, which were lower in the G2 group, along with a reduction in morphine consumption in the same group, although without significant difference.

The administration of 75 mg of pregabalin preoperatively reduces postoperative pain and morphine consumption. All therapeutic strategies should be implemented perioperatively to relieve the patient and prevent the risk of chronic postoperative pain. Controlling postoperative pain allows for early patient mobilization, which is beneficial for better functional outcomes.

Discogenic pain is the most common cause of low back pain (LBP). Intradiscal Pulsed Radiofrequency (ID-PRF) is used for the treatment of discogenic LBP. The effect of Platelet-Rich Plasma (PRP) on IVD degeneration has been investigated in vitro and in animal models, with significant reparative effects. We investigated the efficacy of ID-PRF plus PRP in patients with discogenic LBP.

We collect patients treated with ID-PRF and PRP in our hospital from January 2023 to January 2024. Thirty-four patients were included. The patients were treated with ID-PRF plus PRP into pulpous nucleus. Treatment efficacy was evaluated using the Numeric Rating Scale (NRS-11) at 1, 3 and 6-months. Success was defined as a reduction in NRS11 of 50% or more.

The mean age was 50.1 (SD 9.9) years, with 53% of female patients and 23% of patients received opioids, mainly tramadol. The treated levels were thirteen patients L4-L5, fourteen L5-S1 and five L4-L5 and L5-S1. The preprocedural NRS was 7.76 (SD 1.18) in a 0 to 10 scale. There was a median decrease of NRS of 2 points at 1 month, 4 points at 3 months and 2 points at 6 months, being statistically significant (Kruskall-Wallis p<0.001) (Figure 1). The relief of 50% or more of baseline pain is observed in 46% of patients at the first month and in 60% of patients at 3 and 6 months.

In patients with discogenic LBP, ID-PRF plus PRP significantly decreased pain at one month and this improvement was improved, at 3 and 6 months.

Trans-sacral epiduroscopic plasma decompression (SEPD) refers to the procedure of relieving pressure on epidural structures by utilizing a plasma reaction, conducted through a trans-sacral route. Using bipolar radiofrequency energy for ablation and coagulation, known as the Coblation® technique, it is feasible to decrease intradiscal pressures and disc volume by removing disc material. This study represents the inaugural research on SEPD utilizing a plasma catheter in animals. Its primary objective is to validate the safety of SEPD.

Epiduroscopes were inserted through the sacral hiatus in two pigs and then advanced to the lumbar segment's epidural space.(Figure1) A plasma catheter was inserted through the working channel of the epiduroscope. This catheter was then placed into the epidural structures, where ablation was conducted using a plasma reaction. Following plasma ablation, the walking and physical activity of the two pigs were assessed. One month after the plasma ablation, autopsies were conducted.(Figure2)

Following the experiments, the pigs were subjected to tests for allodynia to assess nerve injuries. However, neither abnormal motor behavior nor any signs of pain, allodynia, or paresis were observed in the pigs. During the autopsy, the spinal cord and spinal nerve roots were dissected and examined histologically under a microscope. However, no thermal damage was observed in the nervous tissues.(Figure3)

In conclusion, SEPD did not demonstrate severe complications in pigs. This suggests that SEPD could be a promising method for spinal decompression in humans.

Lumbar sympathetic ganglion neurolysis (LSGN) has been used for long-term pain relief in patients with complex regional pain syndrome (CRPS). However, the actual effect duration of LSGN has not been accurately measured. This prospective observational study measured the effect duration of LSGN in CRPS patients and investigated the relationship between temperature change and pain relief.

After performing LSGN with 2.5 mL of 99% ethanol, the skin temperatures of both the maximum pain site and the plantar area in the affected and unaffected limbs were measured by infrared thermography(Fig. 1, 2), and pain intensity was assessed before and at 2 weeks, 1 month, and 3 months. The median time to return to baseline temperature was calculated using survival analysis.

The skin temperature increased significantly at all-time points relative to baseline in both regions (maximum pain site: 1.4°C ± 1.0°C, plantar region: 1.28°C ± 0.8°C, all P < 0.001). The median time to return to baseline temperature was 12 (95% confidence interval [CI]: 7.7–16.3) weeks at the maximum pain site and 12 (95% CI: 9.4–14.6) weeks at the plantar area. Pain intensity decreased significantly relative to baseline, at all-time points after LSGN.(Fig. 3, 4)

The effect of LSGN on reducing pain and increasing temperature in the affected extremity was sustained for ≤ 12 weeks post-treatment, with a significant reduction in pain intensity after LSGN. These results support the use of LSGN as a prolonged pain management strategy in patients with CRPS.

Hemipelvectomy and reconstruction with limb salvage stands as the primary treatment for periacetabular pelvic sarcomas. Anesthetic management is challenging due to highly aggressive surgery and the complex pelvic anatomy (Figure 1). Intraoperative bleeding management, coagulation disturbances and postoperative pain are particularly relevant. We describe our clinical practice in these surgeries.

A case series of 10 patients with periacetabular pelvic sarcomas that underwent hemipelvectomy and pelvic reconstruction with custom prosthesis between 2016 and 2022 was analyzed. Approval by IRB was requested (IIBSP-COO-2024-72).

All patients underwent combined epidural and intravenous general anesthesia. Monitoring included arterial pressure waveform for hemodynamic parameters and goal-directed fluid therapy, alongside thromboelastometry for coagulopathy correction guidance. Two patients underwent preoperative arterial embolization. A pre-incisional bolus of 10-15mg/kg tranexamic acid followed by an infusion of 10-15mg/kg over 8 hours was administered. Median blood loss was 2375 ml (1500 – 4500 ml). Intraoperative fluid and transfusion therapy are detailed in Table 1. Four patients required plastic surgical reconstruction. Median surgical time was 7 hours (6.5 – 13.5), ICU stay 2.5 days (1 – 10) and hospital stay 36 days (18 – 116). Epidural infusion of 2mg/ml ropivacaine with 2mcg/ml fentanyl achieved optimal pain control. Two accidental catheter dislodgements were registered (Figure 2).

Pelvic reconstruction with custom prosthesis after large oncologic resection is a long-lasting painful procedure associated with high morbidity. Perioperative management of major bleeding and optimal pain management with epidural analgesia are primary goals for the anesthesiologist. Subcutaneous tunnelling of epidural catheters should be considered to prevent accidental dislodgement.

Postoperative Delirium (PD), Postoperative Neurocognitive Dysfunction (PND) and Postoperative Chronic Persistent Pain (PCPP) are common in geriatric surgery patients and are associated with postoperative acute pain and opioid consumption. ESP block is used as part of multimodal analgesia in spinal surgery. In the present study, the purpose was to test the hypothesis that ESP block applied to patients undergoing lumbar spinal surgery will reduce PD, PND, and PCPP by reducing the severity of acute pain and opioid consumption.

After obtaining Clinical Research Ethics Committee and patient approvals, 128 patients aged 60 years and above who underwent elective lumbar spinal fusion surgery were randomized with or without ESP block. NRS scores and opioid consumption were recorded in the postoperative 24 hours. PD was assessed with the CAM ICU test for 5 days postoperatively or during hospital stay. PCPP was assessed with the Brief Pain Scoring System 3 months after the spinal surgery. PND was assessed with the MOCA scale administered 3 months later.

The number of patients with delirium, cognitive dysfunction, and chronic persistent pain was lower in Group 1 and no statistically significant differences were detected between the groups (p>0.05). In the acute period, NRS scores, and total opioid and rescue analgesic use amounts were significantly higher in Group 2 patients (P<001).

Considering that the ESP block reduces postoperative pain intensity and opioid consumption, contributing to the decrease in the incidence of PD, PND, and PCPP, we believe that it is appropriate to use it for analgesia following vertebra surgeries.

Background: Perioperative administration of benzodiazepines is considered a risk factor for early postoperative cognitive decline; however, the association between Remimazolam, a newly developed ultrashort-acting benzodiazepine for anesthetic purpose and postoperative cognitive decline is under research. Aims: The primary aim of this prospective randomized study was to evaluate whether Remimazolam administration during elective surgery under spinal anesthesia influences the incidence of early cognitive decline in patients with no prior cognitive disorders. Secondary outcomes included the evaluation of mean arterial pressure and heart rate.

80 patients (age>65 years) scheduled for short surgical procedures under spinal anesthesia were randomized 1:1 to receive Propofol (PRO group) or Remimazolam (RMZ group) aiming a Modified Observer’s Assessment of Alertness/Sedation score of 3 or 4. Both groups were assessed through the Mini-Cog test at three time points: preoperative, first 24 hours and 48 hours postoperative.

Both groups were similar in terms of age, gender, BMI, ASA score and comorbidities. Preoperative Mini-Cog score were similar across both groups. Patients receiving Remimazolam demonstrated a better Mini-Cog score at both 24 and 48 hours compared to those receiving Propofol (4,41 vs. 4,0, diff means=-0,41± 0,18, 95%CI 0,79-0,04, p=0,02; 4,3 vs. 3,9, diff means=-0,41± 0,19, 95% CI 0,813-0,0160, p=0,04). Patients in RMZ group had a lower incidence of hypotension and bradycardia during procedural sedation.

Remimazolam usage for procedural sedation is safe and does not worsen early cognitive outcome in older patients undergoing short elective surgical procedures. Furthermore, it offers a better hemodynamic profile which can improve patients outcome.

The prevalence of intraoperative hypotension has garnered significant attention due to its impact on organ perfusion and potential adverse effects. Both spinal anesthesia and sedation contribute to hypotension occurrence, heightening the risk for patients who receive sedative drugs during spinal anesthesia. This study was designed to explore the differences in hypotension frequency between propofol and remimazolam sedation, a traditional and emerging sedative choice respectively, known for their rapid onset and offset of action, during hip surgeries in spinal anesthesia.

A total of 78 patients of age group 20-65 years of American Society of Anesthesiologists grade I-III, posted for hip surgeries under spinal anesthesia were randomly divided into two groups (n=39 each) to receive remimazolam (Group R) or propofol (Group P) infusion targeting a Modified Observer’s Assessment of Alertness/Sedation(MOAA/S) score of 3. The primary outcome was the frequency of hypotensive episodes, defined by mean blood pressure < 65mmHg, in the first hour of infusion. Secondary outcomes included the incidence of hypotension during surgery, other hemodynamic variables, the incidence of rescue phenylephrine use, and postoperative adverse outcomes.

The incidence of hypotension during surgery was significantly lower with remimazolam than propofol(23 vs 33; P=0.02). However, there were no significant differences in the frequency of hypotensive episodes, other hemodynamic variables, use of hemodynamic rescue drugs, or postoperative adverse outcomes.

Remimazolam, with its minimal effects on hemodynamic, could be a valuable adjunct for intraoperative sedation during hip surgery under spinal anesthesia.

Incentive spirometry is a method commonly used for prevention of postoperative pulmonary complications in patients after abdominal surgery. However, pain after surgery can cause diminished incentive spirometry volumes. By effectively controlling postoperative pain, patient performance in incentive spirometry can be enhanced. The aim of this study is to determine whether erector spinae plane (ESP) block added to a standard analgesic regimen can improve incentive spirometry performance in patients after open abdominal surgery.

This retrospective cohort study was approved by the Institutional Ethics Review Committee of St. Luke’s Medical Center. The records of 110 patients who underwent open abdominal surgery were reviewed. For the opioid-based group (n=55), a standard analgesic regimen of Paracetamol and a Non-steroidal Anti-inflammatory Drug (Parecoxib, Ketorolac or Dexketoprofen) was given in the first 24 hours post-surgery. Tramadol, Oxycodone, or Fentanyl was given as needed for breakthrough pain. For the ESP group (n=55), ultrasound-guided single shot bilateral ESP block with 0.2%-0.4% Ropivacaine was administered as an adjunct to the aforementioned standard analgesic regimen. The first recorded incentive spirometry scores in the first 24 hours postoperatively were compared between the two groups.

Mean peak effort volume on incentive spirometry within 24 hours postoperatively was significantly higher with the ESP group (1212.7 ml +/- 523.4 ml) compared to the opioid-based group (541.8 ml +/- 437.7 ml) with p-value <0.001 (Fig 1).

Addition of ESP block to the analgesic regimen of patients undergoing abdominal surgeries facilitates more effective incentive spirometry compared to an opioid-based analgesic regimen alone.

Total hip arthroplasty (THA) is a frequent orthopedic procedure, leading to substantial perioperative pain. Suprainguinal fascia iliaca block (SIFIB) and anterior quadratus lumborum block (A-QLB) are two modern regional anesthesia methods used for THA analgesia. This study compares their efficacy in THA via a posterior approach.

This randomized, assessor blinded study was conducted between January 2023 and May 2024 following IRB approval and registration (NCT05684471). ASA I-III patients aged 18-75y scheduled for THA were included. Blocks were performedat the end of surgery with 50 mL of 0.25% bupivacaine in the SIFIB group, and with 40 mL of 0.25% bupivacaine in the A-QLB group. The primary outcome assessed was the 24-hour cumulative morphine requirement, delivered via patient-controlled analgesia (PCA). Secondary outcomes encompassed pain scores, time to first opioid demand, and presence of quadriceps weakness. Additionally, occurrences of nausea, vomiting, and Quality of Recovery-15 (QoR-15) scores were recorded.

In this study of 65 patients (SIFIB: 33, A-QLB: 32), morphine consumption at various time points showed no difference between groups (p>0.05). At 24 hours, opioid usage was similar (SIFIB: 9.94±7.64 mg, A-QLB: 11.31±6.85 mg, p: 0.449). Pain scores, time to first analgesic requirement, and QoR scores were comparable (p>0.05). Notably, quadriceps weakness varied, with the SIFIB group having an 18/15 absence/presence ratio and the A-QLB group a 25/7 ratio by 24 hours post-op.

Although opioid demands and pain scores showed no significant differences among patients undergoing THA with either SIFIB or A-QLB for postoperative pain relief, A-QLB demonstrated superior motor sparing effects.

Suprascapular nerve entrapment syndrome (SSNES) is a neuropathy caused by compression of the nerve. Previous research has demonstrated that it often causes the weakness of supraspinatus muscles, as well as pain of the shoulder. We considered that the supraspinatus muscle cross-sectional area (SMCSA) might be a morphological parameter to analyze SSNES.

We acquired supraspinatus muscle data from 10 patients with SSNES and from 10 control subjects who revealed no evidence of SSNES. T1-weighted sagittal magnetic resonance imaging of the shoulder (MRI-S) images were acquired. We analyzed the supraspinatus muscle thickness (SMT) and SMCSA at the shoulder on the MRI-S using our image analysis program. The SMCSA was measured as the whole supraspinatus muscle cross-sectional area that was most hypertrophied in the sagittal MRI-S images. The SMT was measured as the thickest level of supraspinatus muscle.

The mean SMT was 20.05 ± 1.85mm in the normal group and 18.16 ± 1.58mm in the SSNES group. The mean SMCSA was 653.24 ± 100.55mm2 in the normal group and 503.06 ± 117.89mm2 in the SSNES group. SSNES patients had significantly lower SMT (p < 0.001) and SMCSA (p < 0.001) than the normal group. ROC curve analysis suggested that the best cut-off scores of the SMT was 18.49 mm, with 70.0% sensitivity, 70.0% specificity, and an AUC of 0.80 (95% CI, 0.60-0.99). The optimal cut-off value of the SMCSA was 612.60mm2, with 80.0% sensitivity, 80.0% specificity, and AUC of 0.85 (95% CI, 0.68-1.00).

The SMCSA test is more sensitive than the SMT test.

Antimicrobial resistance(AMR) has become a global issue. Not only decreasing the treatment options but a serious threat to low-income countries associated with both misuse of antibiotics. Antibiogram is essential for a hospital to track changes in AMR and to guide empirical antimicrobial therapy. The goals of the current study is to ascertain burden of nosocomial infections in ICU patients, pinpoint involved pathogens, and sensitivity to antimicrobial drugs.

This study was retrospective cross-sectional in nature. Study was conducted at SICU of Doctors Hospital and Medical Center, Lahore over a period of one year from January 2021 to December 2021. Patients of both genders with age above 18years were included in this study. 364 patients were recorded for the purpose of study and analyzed. All cultures were processed in accordance with standard microbiological protocols defined by CLSI.The antibiogram was constructed according to CLSI and Stanford University’s web-based antibiogram.

Among 364 patients analyzed in the study, the cultures obtained from different sites were Blood (54%), Urine (33%) and tracheal (13%). Among blood cultures, no organism was isolated. E coli was most common organism among urine and Klebsiella Pneumonia was most frequently encountered in tracheal cultures. Vancomycin and Linezolid showed zero percent resistance to Staphylococcus. Collistin showed zero percent resistance for Acinetobacter and Klebsiella.

The high frequency of multidrug resistance bacteria in ICU suggests that we need to prescribe broad-spectrum antibiotics more wisely to reduce pressure on sensitive strains. Vancomycin and Linezolid for Gram positive organisms and Collistin for Gram negative organisms.

Chronic pain is a prevalent and debilitating condition affecting millions of women worldwide and often resulting from conditions such as fibromyalgia, endometriosis, and chronic migraines. Managing chronic pain effectively is crucial for improving patients' quality of life, yet nurses face numerous challenges in delivering optimal care. This review aims to identify and analyze the primary challenges faced by nurses in treating chronic pain among women, exploring both clinical and non-clinical factors.

A comprehensive literature review was conducted, analyzing peer-reviewed articles, clinical studies, and professional reports published between 2010 and 2023. Key databases searched included PubMed, CINAHL, and and PsycINFO. The review focused on studies that addressed challenges in pain assessment, communication, interdisciplinary collaboration, education, and psychosocial factors in the context of chronic pain management in women.

Nurses often encounter difficulties in accurately assessing chronic pain due to its subjective nature, variability in pain expression, and the influence of emotional and psychological factors. Effective communication between nurses and patients is critical for understanding pain levels and treatment efficacy. Third significant challenge id interdisciplinary collaboration. Chronic pain management requires a multidisciplinary approach. However, nurses frequently face obstacles in coordinating with other healthcare professionals, leading to fragmented care and inconsistent pain management strategies. There is also a need for enhanced education and training for nurses in pain management techniques, pharmacology, and non-pharmacological interventions alongside with the need to psychological support.

Nurses encounter multiple challenges in managing chronic pain among women, stemming from issues in pain assessment, communication, interdisciplinary collaboration, education, and psychosocial support.

This study aims to use bibliometric methods to identify the contribution of countries, journals, authors, research themes, and emerging trends in artificial intelligence (AI) in pain.

Articles on AI in pain were obtained from the Web of Science database which was accessed on 22 February 2024. TheVOSviewer program was used to visualize trends in research on artificial intelligence in pain.

Analyses of 767 original articles revealed that the total number of publications has continually increased over the last 10 years. From 2014 to 2023, it was determined that there was an increase in the number of studies on the use of AI in pain [n:13(2014); n:240(2023)] (Figure 1). Scientific Reports (n=31) and Journal of Clinical Medicine are the journals that published the most studies on the use of AI in pain (n=22). The countries with the highest number of studies are the United States (n=174), China (n=131), South Korea (n=88), Germany (n=72), Taiwan (n=59), England (n=54), Canada (n=43), Italy (n=41), Netherlands (n=36), India (n=35), Spain (n=34), Japan (n=33), Australia (n=21), Switzerland (n=24), Saudi Arabia (n=20). In the keyword co-occurrence analysis, 12 clusters were found; machine learning; spine, pain perception, pain, mhealth, pain management, blood sampling, epidural anesthesia, acute coronary syndrome, algorithmic approach, and pain assessment (Figure 2).

The present study evaluated research on acupuncture for pain control using bibliometric methods and revealed current trends in artificial intelligence in pain research, as well as potential future hot spots of research in this field.

Stabbing pain deriving from a herniated disc at L4-L5, L5-S1 levels poses a significant clinical challenge. Some patients diagnosed with lumbar disc herniation experience not only typical pain but also hyperalgesia over the sensory territory of the common peroneal nerve. Therefore, exhaustive approaches are emerging for effective pain management. Among these emerging techniques are transforaminal steroid injections associated with common peroneal nerve blockade. Consequently, the study aims to investigate the potential synergistic effects of integrating these two interventions to improve pain relief in patients with lumbar radiculopathy.

Prospective, single-center study conducted from September 2022 to September 2023. Included patients were aged 25 to 65 years, with L4-L5, L5-S1 radicular pain, and discomfort throughout the common peroneal nerve's sensory territory. Participants were blindly assigned to two groups: the first receiving ultrasound-guided common peroneal nerve blockade in addition to transforaminal steroid epidural injection, while the second group received only the standard transforaminal injection method. Pain intensity was assessed using a visual analog scale (VAS) for all participants before and after interventions to evaluate changes in scores and duration of pain relief.

180 patients were included in the study, with 60% of the population being female and 40% male. Preliminary results showed a remarkable depletion in pain scores after combining both interventions in 100% of participants.

This combined approach appears promising for managing severe radiculopathy. Further investigations through larger-scale studies with long-term follow-up are crucial to confirm these findings and establish the role of this combined intervention in the management of lumbar radiculopathies.

Ankylosing spondylitis (AS), a persistent inflammatory condition targeting sacroiliac joints and spine, induces stiffness and a distinctive bamboo spine, presenting challenges in anesthetic management due to airway complexity and spinal rigidity. The aim of this is to determine whether an ultrasound-assisted technique could reduce the number of needle passes required for a successful dural puncture in patients with abnormal spinal anatomy compared with conventional landmark-guided techniques

This prospective randomized controlled comparative study will be conducted in cooperative patients aged between 18 and 60 years of either sex, belonging to American Society of Anaesthesiologists physical status I and II, scheduled to undergo elective total hip replacement under spinal anesthesia. Patients were randomly assigned to two groups via a computer-generated random table: Group 1 received ultrasound-guided subarachnoid blocks, and Group 2 received blocks using the surface landmark technique After taking sterile precautions, the puncture site was prepared, and the subarachnoid block was administered using the assigned method. Hemodynamic variables such as heart rate, mean arterial pressure, SpO2, and ECG readings were continuously monitored, along with the total number of attempts taken to administer the block.

In Group I using the USG method, most participants achieved block success on the first attempt, whereas Group II using the landmark technique had a lower first-attempt success rate, resulting in a significant difference. The USG method marginally increased procedure time, though not significantly.

The preprocedural ultrasound-assisted sub arachnoid block can increase the first-pass success rate in patients of ankylosing spondylitis undergoing total hip replacement surgery

The electrical impedance tomography (EIT) measures non-invasively atelectasis, through changes in the thoracic impedance. The purpose of the present study was to assess by EIT the effects of lumbar epidural analgesia on ventilation, in pregnant women, during labor, in sitting position.

After Institutional Ethics Committee approval and written consent, 37 adult ASA 2 at term pregnant patients were studied. The belt of the EIT was placed around the patient’s thorax at Th4–Th6 level. The study recordings were done 10 minutes before and after insertion and loading of the epidural analgesia. Student’s paired t-test with the Bonferroni correction was applied to compare data before and after epidural analgesia, for the global and regional ventilation. Data are expressed as mean [95%CI].

Good levels of analgesia were obtained in all cases (VAS 8,43 vs 0,97 [ -8,208 to -6,710], p<0.001), with upper sensory levels reaching from Th4 to Th10. Atelectasis was seen in all patients before the epidural analgesia, with better ventilated regions centrally than peripherally. No effects of epidural analgesia on atelectasis were noted neither for the global, nor for regional ventilation (Figure 1).

This is the first study assessing lung atelectasis before and after epidural analgesia during labor. The changes in lung volumes, as demonstrated by this study, are mostly due rather to the mechanical pushing of the abdominal content towards the diaphragm and lung, and not to shallow breathing due to pain. Further studies in left lateral position are needed.

This comprehensive review critically assesses the anatomical precision of adductor canal block (ACB) and its impact on analgesic efficacy in total knee arthroplasty (TKA). By conducting subgroup analyses on the femoral triangle block (FTB), proximal ACB (p-ACB), and distal ACB (d-ACB), this study investigates the motor-sparing effects and analgesic efficacy of ultrasound-guided techniques. The intricate anatomical complexities within the femoral triangle, adductor canal, and subsartorial region are synthesized to elucidate the intricacies of nerve targeting.

A critical evaluation of published randomized controlled trials from 2013 to 2023 revealed flaws in the technique of ACB administration, leading to potentially misleading conclusions. To address these shortcomings, a novel approach called Dual subsartorial block (DSB) is advocated, which rectifies the identified flaws and provides superior analgesia for TKA by covering both the anterior and posterior components of pain.

The findings highlight the inadequacy of conventional ACB methods in achieving procedure-specific analgesia, underscoring the importance of anatomical precision and nerve localization. In contrast, the DSB approach shows promise by leveraging selective motor effects and optimizing local anesthetic delivery.

This study emphasizes the necessity of refining anatomical representations for procedure-specific analgesia in TKA. Existing randomized controlled trials and meta-analyses are critiqued for proposing guidelines based on flawed anatomical understanding. By delineating the nuances of ACB and advocating for DSB, a paradigm shift towards tailored analgesic strategies is encouraged, aiming to enhance patient outcomes and post-surgical recovery.

Administration of steroids in lumbar transforaminal epidural injection in lumbar radicular pain is considered one of the preferred treatment methods, though associated with some complications. Adding magnesium sulfate to local anesthetics has potentiate the effects of peripheral and neuraxial blocks. The effects and side effects of triamcinolone and magnesium sulfate in the lumbar transforaminal epidural injections are investigated in the present study.

Sixty patients, aged 40 - 70 years, suffering from unilateral lumbar radicular pain arising from the lumbar disc protrusion were equally divided into two groups of triamcinolone (T) and magnesium (M). They all underwent fluoroscopic guided lumbar transforaminal epidural injections. In the T group, the injection solution contained triamcinolone (20 mg) plus ropivacaine (0.2%), and in M group was magnesium (150mg) plus ropivacaine (0.2%). If the spinal nerve involvement was in two levels, the same injection solution would be repeated. Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured at 0, 2 weeks, 1, and 3 months post-procedure. The potential complications were evaluated.

There was a statistically significant improvement in pain score (VAS) and functional disability (ODI) during the measurement times in the both groups (p<0.05). The pain intensity and disability index were not significantly different between the triamcinolone and magnesium groups (p>0.05). No complications were observed in both groups.

The lumbar transforaminal epidural injection with triamcinolone or magnesium attenuates lumbar radicular pain. In patients where corticosteroid is not a suitable adjuvant to local anesthetic, or its use is limited, magnesium may be an appropriate alternative.

The ambitious goals of crewed deep space missions, like Nasa's Artemis program and SpaceX's colonization targets, require preparations for potential astronaut health crises. Innovative solutions are necessary to overcome the challenges of administering anesthesia in the unique environment of space and the physiologic changes associated with prolonged microgravity exposure. Regional anesthesia offers a viable solution to these challenges, but its feasibility is yet to be tested.

Our study assessed the feasibility of single-shot peripheral nerve blocks in a simulated microgravity environment (free-floating underwater) using a meat model. We randomized forty meat models to be injected under simulated microgravity and normal Earth gravity conditions. Post-injection, blinded assessors determined success rates. Assessed parameters included, "time to block", ease of needle placement, and ease of image acquisition.

Block success rates were comparable in both scenarios (80% normal gravity versus 85% microgravity, p > 0.999) and there was no difference in the rate of accidental intra-neural injections (5% versus 5%). The median time to block on land was 27 [IQR 21-69] seconds versus 35 [IQR 22-48] seconds in simulated microgravity (p = 0.751). Ease of needle placement and ease of image acquisition were similar in both conditions.

Despite challenges, regional anesthesia appears to be feasible in simulated microgravity. While our model is not a perfect analogue to true space conditions, it provides a foundation for subsequent research into the provision of anesthesia and analgesia during crewed space missions.

This study's objective was to assess the effectiveness and safety of percutaneous balloon compression (PBC) versus other surgical modalities（microvascular decompression [MVD]、radiofrequency thermocoagulation [RFT]、glycerol rhizolysis [GR]、gamma knife radiosurgery [GKRS]）for treating primary trigeminal neuralgia (PTN).

A thorough search was conducted throughout the six electronic databases of PubMed, Embase, Web of Science, CNKI, Wanfang Date and VIP, with a timeframe from the creation of the database to August 2023. We selected the clinical studies that included PBC compared with MVD, RFT, GR, or GKRS for the treatment of primary trigeminal nerve and performed Meta-analysis using Review Manager 5.4 and Stata 12.0.

It included 29 studies in total. Among the included studies, there was only 1 study in each of the PBC versus GR group and the PBC versus GKRS group, which did not allow for meta-analysis, so these two subgroups were excluded. We found that the pain relief at last follow-up of PBC much more than RFT; the reccurence of pain of PBC much more than MVD. PBC was associated with a significantly higher incidence of facial numbness, a noticeably higher incidence of masticatory muscle weakening and incidence of herpes simplex compared with MVD and RFT, respectively.

PBC was superior to RFT for pain relief at last follow-up in primary trigeminal neuralgia. PBC was linked to an increased likelihood of pain recurrence. Following PBC treatment, there was a significant increase in the incidence of three common complications (facial numbness, masticatory muscle weakness, and herpes simplex).

Osteoarthritis (OA) of the trapeziometacarpal (TMC) joint is a common disabling condition with potential surgical resolution. However, complications following these procedures can include superficial radial neuropathy, contributing to hand disability. The aim of our study was to analyze pain management by neuromodulation of the superficial radial nerve (SRN).

Patients undergoing TMC OA surgical procedures at Hospital Center between March 2012 and March 2022 were included. SRN diagnosis block was performed at the first visit with local anesthetic. One month after a successful diagnostic nerve block, pulsed radiofrequency (PRF) of the SRN was performed. Primary endpoint was pain at rest and the secondary outcomes were: hand grip, Functional Index Questionnaire (FIHOA) and Kapandji score.

30 patients met the inclusion criteria. Of the total, 13 patients reported pain and paresthesia on the dorsolateral aspect of the hand, but only 6 patients agreed to participate. Of the total patients, 5 were female, with 2 patients reporting symptoms bilaterally. Pain at rest was described with a median of 8 [IQR 7-8] at baseline and 0 [IQR 0-1,24] after PFR (P = 0.011). Median hand grip (kg) after PFR was 26.8 [IQR 24-31.6] compared to 23.3 [IQR 22.5-25.7] from baseline (P = 0.025) and Kapandji score improved from 6 [IQR 5.8-7.3] from baseline to 7 [IQR 6-8] (P = 0.102). FIHOA index improved 16.5 [IQR 10-21] at baseline to 13.5 [IQR 7.8-18] (P = 0.02).

Neuromodulation of SRN may represent a safe and effective approach to treat pain associated with TMC OA surgery.

The dose of local anaesthetics is reduced when using ultrasound (USG) for supraclavicular brachial plexus block (SCBPB). The aim of this study is to observe the clinical effectiveness of combined fentanyl and dexamethasone in 0.5% 9ml bupivacaine with USG and nerve locator guided SCBPB.

This was a prospective double blind randomised control trial. After assessing inclusion and exclusion criteria, total 72 patients were included (gr-a: 36, gr-b: 36). All patients received USG and electrical nerve locator guided SCBPB. Drug was injected with multi-injection technique within the brachial plexus sheath with current intensity 0.3 mA at 0.1 ms duration. Control group (gr-a) received 20 ml 0.5% bupivacaine, Gr-B received 13 ml of drug soup containing 9 ml bupivacaine 0.5%, fentanyl 100 μg, dexamethasone 10 mg. All patient received morphine patient controlled analgesia in postoperative period.

Mean time to sensory block was 11.8 minutes (gr-a) and 14.7 minutes (gr-b). Mean time to motor block was 15.6 minutes (gr-a) and 23.5 minutes (gr-b). Mean duration of sensory block was 555.5 minutes (gr-a) and 528.3 minutes (gr-b). Mean duration of motor block was 452.6 minutes (gr-a) and 245.7 minutes (gr-b). Mean morphine requirement in postoperative period 14.2 mg (gr-a) and 8.3 mg (gr-b). Postoperative morphine consumption in first 24 hours was 14.2 mg (gr-a) and 8.3 mg (gr-b).

Combined dexamethasone and fentanyl with low volume bupivacaine doesn't shorten time to block initiation and produce short duration of motor block but reduces postoperative opioid consumption.

Same-day hip arthroplasty (SDHA) is becoming increasingly popular due to its association with quicker rehabilitation and enhanced patient satisfaction. However, standard guidelines for discharging patients after SDHA are lacking. Reported discharge rates range between 88% to 95%, and readmission rates vary between 0.03 to 4.6%. This study reports our experience with SDHA at our institution in Genk, Belgium.

We analyzed data from patients scheduled for SDHA over a 14-month period. The perioperative protocol included short-acting spinal anesthesia, pericapsular nerve group block, and a standardized multimodal analgesia regimen. Patient demographics such as age and BMI were collected. Medical records were searched for incidence of complications including nausea, vomiting, urinary retention, hypotension, and vagal responses. Reasons for delays in same-day discharge and rate of readmissions were also assessed.

Ninety-three patients underwent the SDHA pathway. The average age was 57 (11) years and the average BMI of 26 (4) kg/m2, while 57% were men. Eighty three percent were discharged on the day of surgery. Factors affecting discharge included orthostatic hypotension and vasovagal reactions (31%), nausea and vomiting, (12%), wound oozing (6%), and/or inadequate analgesia (12%). The average pain score on the first postoperative day was 3,7 (1,8) and there were no readmissions.

Discharge rates in our institution align with the existing literature. The most common impediments to timely discharge were orthostatic hypotension and vasovagal reactions. We plan to further investigate predisposing factors and develop strategies to address these obstacles, with the goal of enhancing our discharge rates.

Total knee arthroplasty (TKA) is associated with severe postoperative pain. A combination of motor-sparing blocks (femoral triangle block) with multimodal analgesia is the analgesic strategy in our center. We aimed to assess the efficacy of analgesia in patients receiving TKA.

Data was collected from patients undergoing TKA from November to December 2023. Patients received our institutional standard analgesia protocol, which includes a femoral triangle block, and subcutaneous morphine every 4 hours as per patient request. The acute pain service team assessed the maximum pain score using a Numeric Rating Scale (NRS) and the cumulative dose of subcutaneous morphine the first 24 hours following surgery.

The postoperative pain of 75 patients who underwent TKA was examined for the first 24 hours. The median postoperative pain score, measured using the NRS, was 5, with an interquartile range of 2 to 7. Severe pain (NRS ≥ 8) was experienced by 20% of patients (n=15). Forty percent (n=30) required postoperative subcutaneous morphine, with a mean cumulative dose of 9.6 mg (standard deviation 8.0 mg). Figure 1 presents a histogram of the postoperative NRS pain scores, annotated with the cumulative morphine doses.

This study revealed that TKA is a painful procedure and that 40% of the patients received postoperative opioids. Systematic assessment and audit of the efficacy of postoperative analgesia protocols are essential and can provide information for optimizing pain management strategies. In fact, based on these findings we decided to start a project at our center that could improve morphine administration following TKA.

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

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

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

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

Patients undergoing spine surgery experience intense pain in the postoperative period. Multimodal pain management protocols, including regional anaesthetic techniques are one of the cornerstones of the enhanced recovery after surgery pathway. We compared continuous ESP block and opioid-based intravenous (IV) patient-controlled analgesia (PCA) following multi-level spine surgery.

The present prospective, randomized, open-label study enrolled 54 patients scheduled for elective multi-level spine surgery who were randomly divided into ESP and PCA group. Postoperatively, bilateral continuous ESP block was performed in patients who were allocated to group ESP. All patients were given fentanyl-based IV PCA pumps. For patients in group PCA, the background infusion rate was kept at 1 µg/kg/hr with a bolus dose of 0.5 µg/kg and lockout interval of 30 min while in group ESP, a similar PCA setting without background infusion was set. The primary objective of the study was to compare postoperative analgesia using visual analogue scale (VAS) score. Secondary objectives were comparison of total opioid consumption, number of rescue analgesics used and satisfaction score.

The worst VAS scores at rest and during movement were significantly lower in group ESP at all predefined time points (p<0.05). The total opioid consumed over 24h was significantly lower in patients receiving ESP block compared to those maintained on IV PCA (p<0.05). More rescue analgesic doses were required with higher opioid-related side effects in group PCA.

Continuous ESP block is a safer and more effective alternative to opioid-based analgesia as a component of multimodal analgesia protocol for patients undergoing multilevel spine surgery.

Because of the high initial cost of intrathecal drug delivery (ITDD)-therapy, this study investigated the cost-effectiveness and cost-utility of ITDD-therapy in refractory cancer pain management in Thailand over the past ten years.

The retrospective study was conducted in cancer pain patients who underwent ITDD-therapy from January 2011-2021 at three university hospitals. Clinical outcomes included the numerical rating scale (NRS), Palliative Performance Scale and the European-Quality of Life Measure-5 Domain. The direct medical and non-medical, as well as indirect costs, were also recorded. Cost-effectiveness and cost-utility analyses were performed comparing ITDD-therapy with conventional therapy (interpolated from costs of the same patient before having ITDD-therapy).

Twenty patients (F:M: 10:10) aged 60 ± 15 years who underwent implantation of an intrathecal percutaneous port (IT-port; n =15) or programmable intrathecal pump (IT-pump; n =5) were included. The median survival time was 78 (IQR 121-54) days after ITDD therapy. At 2-month follow-up, the incremental cost-effectiveness ratio (ICER)/ pain reduction of an IT port (US $862.73/NRS reduction/lifetime) was lower than for an IT-pump group (US $ 2,635.68/NRS reduction/lifetime) compared with continued conventional therapy. The ICER/quality-adjusted life years (QALY)-gained for an IT-port compared with conventional treatment was US $93,999.31/QALY-gained, which is above the cost-effectiveness threshold for Thailand.

The cost-effectiveness and cost-utility of IT-port therapy for cancer pain was high relative to the cost of living in Thailand, above the cost-effectiveness threshold. Prospective cost-analysis studies enrolling more patients with diverse cancers that investigate the benefit of early ITDD-therapy with different-priced devices are warranted.

Postoperative pain management has shifted towards multimodal analgesia in an effort to limit opioid use. Moreover, there has been a recent shift towards outpatient surgery for a variety of surgeries. It is unclear how this has impacted trends in use of multimodal analgesia. Here, we report trends in use of individual non-opioid analgesic modes for total knee and hip arthroplasties (THA/TKA), stratified by inpatient/outpatient settings.

After institutional review board approval (#2012-050), this retrospective study included all primary THA (n=1,248,761 all / n=21,922 outpatient) and TKAs (n=2,157,056 all / n=54,997 outpatient) from 2006-2022 for both inpatient/outpatient surgeries and 2018-2022 for outpatient surgeries (national US Premier Healthcare data). We calculated the annual percent use of eight non-opioid analgesic modes: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), COX-2-inhibitors, ketamine, gabapentinoids, steroids, peripheral nerve blocks (PNB), and neuraxial anesthesia. Data were stratified by procedure type and inpatient/outpatient setting.

Visual representation of trends can be found in Figures 1 and 2. From 2006-2022, PNB use increased more rapidly in TKAs (13.8%-29.7%) than in THAs (9.0%-12.3%). Neuraxial anesthesia followed the same trend in TKAs (31.0%-39.0%) compared to THAs (27.0%-29.0%). Among both procedures and settings, the use of NSAID’s, COX-2-inhibitors, and gabapentinoids peaked in 2017-2018 and have since declined.

Overall, similar trends among most modes of analgesia existed for both TKAs and THAs, excluding PNBs and neuraxial anesthesia use which increased more rapidly in TKAs. Several modes have declined since 2017-2018. Further research is needed to elucidate mechanisms behind these trends.

Music or Silence has proven effective in many medical conditions undergoing procedures with various depth of anesthesia. We aimed that integrating music or noise-blocking interventions could lead to reduced anxiety, pain, and analgesic requirements and increased satisfaction patients undergoing general anesthesia.

We conducted a prospective randomized study involving 90 patients undergoing traumatic surgeries in the OR. Patients were divided into 3 groups; music (earphones with music), silence (earphones with no music), and noise (exposure to ambient) groups. Objective and subjective assessments, including validated anxiety scales (STAI-trait and STAI-state) pain, and satisfaction were measured pre- and post-operatively to measure the impact of interventions on patient well-being.

Significant reductions in anxiety (p= 0.032) and pain scores (p= 0.021) were observed in the Music and Silence groups compared to the Noise group. Satisfaction scores were higher in these groups (p = 0.026). No differences in analgesic use except rescue analgesics, hemodynamic variables, or intraoperative drug amounts were noted. The environmental noise was consistent across groups, and no postoperative side effects were reported. Correlations between postoperative STAI-state and pain scores were notable.

Harnessing the power of music and noise-blocking interventions dramatically reduced anxiety, significantly alleviated pain, cut down on analgesic use, and vastly increased patient satisfaction in the high-stress environment of trauma operating rooms. Embracing the therapeutic potential of music and silence is paramount for revolutionizing the intraoperative experience and transforming patient care in these intense surgical settings.

Epidural catheter placement is crucial for effective postoperative pain management in abdominal surgery. However, its success relies on accurate localization within the epidural space, which can be challenging due to anatomical variations and operator-dependent factors. In this study, ultrasound is compared with sensory assessment of the block (pinprick and cold pressure). Ultrasound, particularly using color Doppler and M-mode, has shown promise for catheter localization, but its interobserver and intraobserver variability remain unclear.

Determine the interobserver and intraobserver variability of ultrasound in detecting epidural catheters and assessing their efficacy in abdominal surgery. Methods: A diagnostic test study was conducted to analyze interobserver and intraobserver variability in measuring skin-to-posterior complex and skin-to-anterior complex distances and determining catheter placement in the epidural space using qualitative method with color Doppler and M-mode ultrasound. Three anesthesiologists were included. Statistical analysis, including intraclass correlation for continuous variables and kappa coefficient for categorical variables, was performed. Bland-Altman plots were constructed to visualize agreement between observers.

The study included 125 patients who provided consent to participate, 75 were women. Preliminary analysis revealed a good intraclass correlation for distances. Kappa index for M-mode was better (see table 1 and 2), indicating consistency in measurements and catheter placement assessment.

Initial findings suggest promising interobserver and intra-observer agreement in ultrasound-guided epidural catheter localization and efficacy assessment. The low inter- and intra-observer variability observed in this study supports the clinical applicability of ultrasound. Further analysis with a larger sample size is warranted to validate these results.

A pericapsular nerve group (PENG) block can be used to reduce pain after hip surgery as part of a multimodal postoperative pain management. This approach targets the sensory branches of the anterior portion of the hip capsule originating from the lumbar plexus (L2-L4). More research is needed to fully understand the characteristics of this block. Since this approach is a field block, its efficacy is volume-dependent. In this study, we compared the spread of different volumes of dye using a PENG block approach in two body donors.

Two male unembalmed human bodies were obtained from the human body donation program of the university (with written informed consent). The four hip regions were injected respectively with 5 ml, 10 ml, 15 ml or 20 ml of a custom-made mixture (10% latex, 1.5% methylene blue 10 mg/ml and 88.5% water) by an experienced anaesthesiologist under ultrasound guidance. The spread of the injectates was measured and compared using dissection of the hip regions.

Injections with 5 and 10 ml of dye did not result in staining of the targeted nerves. With 15 and 20 ml of dye, we observed a posterocranial spread without staining the targeted femoral, obturator or accessory obturator nerves. The dye was located on top of the ilium.

To our knowledge, this is the first time a spread over the ilium has been described. This atypical posterocranial spread might explain clinical failure of PENG blocks in some patients, suggesting a steep learning curve to apply this relatively new block effectively.

While much research exists on patterns of pain scores in the perioperative period, much less data exists on longer term follow-up of pain scores, especially after total knee arthroplasty (TKA). Re-using data from a published prospective study capturing patients' pain scores recorded over 29 days post-TKA, we aimed to assess whether unsupervised machine learning can discern distinct postoperative recovery patterns.

This study was approved by an Institutional Review Board as it re-used data from a published study that prospectively enrolled 103 patients undergoing primary TKA (2020-2021) at a single university hospital. Patients recorded daily numeric rating scale pain scores at morning, lunchtime, evening, and nighttime for 29 days. A K-Means clustering algorithm (unsupervised) was applied to identify distinct pain recovery patterns after which the identified recovery groups were compared based on available patient and surgical characteristics.

Two clusters of patients with distinct recovery patterns were discovered: patients in Cluster 1 (versus Cluster 2) had higher pain levels throughout the recovery period (Figure 1); Cluster 1 also represented patients that were more likely female and with higher Knee Society Scores (KSS) at both week 1 and 4 post-TKA, as well as a higher KSS Functional Score at week 1. (Table 1)

Machine learning algorithms applied to longitudinal pain level data have identified two distinct postoperative recovery patterns after TKA. Notably, patients who experienced higher pain levels early postoperatively exhibited consistently higher pain levels later within the first month of recovery.

The large surgical incisions and manipulation of internal organs in open gastrectomy cause severe postoperative pain. Intrathecal morphine (ITM) has been evidenced to provide effective analgesia in abdominal surgeries. Erector spinae plane block (ESPB) has the potential to provide both somatic and visceral sensory block. This study aimed to compare the analgesic efficacy of ESPB and ITM in open gastrectomy.

Adult patients with American Society of Anesthesiologists physical status II-III undergoing elective open gastrectomy surgery were randomly assigned to either the ESPB or ITM groups. Before induction of anesthesia, patients received either 200 mcg ITM or bilateral ESPB using 20 mL of 0.25% bupivacaine. The primary outcome was to compare first postoperative 24-hour total opioid consumption, while secondary outcomes included evaluating postoperative pain using NRS scores and CAPA Tool, requirement for rescue analgesia, and assessing postoperative complications.

Sixty-three patients were included in the analysis. 24-hour opioid consumption was similar in ESPB and ITM groups (mean 24.5 ± 17.56 and 23.33 ± 16.3 respectively) (p = 0.831). Intraoperative remifentanyl consumption was lower in ESPB group (p = 0.002). NRS scores were <4/10 at all time intervals and similar among the groups. ITM group experienced notably superior comfort levels at 2nd hour (p = 0.008) and better pain management at 2nd and 6th hours compared to the ESPB group (p = 0.025; p = 0.006, respectively) according to CAPA Tool.

Ultrasound-guided ESPB resulted in similar total opioid consumption with ITM at the first 24 hour after open gastrectomy.

3D software technology has been utilized in various medical fields by enabling the creation of reliable models with excellent details for both normal and pathological anatomy. The aim of this study is to compare our conventional epidural/spinal anesthesia practices with the preoperative personalized real-sized 3D modeling obtained in a group of patients where difficult neuraxial anesthesia application is anticipated during preoperative anesthesia examination.

Approval was received from the Ege University medical research ethics committee.(19-10.1T/63-2019) Twenty patients over the age of 18, who were anticipated to have difficult neuraxial intervention due to ankylosing spondylitis or operated lumbar disc herniation, and had completed preoperative radiological examinations were included in the study, and archive CT images were evaluated. The cases were divided into 2 groups, one group (Group N) (n=10) received anesthesia without using a model, and in the other group (Group D) (n=10), personalized 3D models obtained from the images were used before and during anesthesia.

Successful anesthesia application was achieved in 100% of cases where 3D models were used, whereas this rate was 80% in cases where models were not used. The success rate in the first attempt was 80% in cases where 3D models were used, while it was 20% in cases where models were not used.

We concluded that 3D modeling increases the success of anesthesia application in cases where difficult neuraxial anesthesia is anticipated while potentially reducing the risk of complications due to multiple attempts.

Arthroscopic shoulder repair (ASR) is less invasive than open surgery, yet perioperative pain management poses challenges. While the interscalene brachial plexus block is effective, its complications drive exploration of alternative techniques. Studies demonstrate analgesic efficacy of sub-omohyoid plane (SOP) block and combinations of infraclavicular brachial plexus block (costoclavicular approach, CC) with superficial cervical plexus (SCP) block comparable to interscalene block. Our study aims to compare their analgesic efficacy, pain scores, complications, and block properties.

This assessor-blinded study (January 2023 - May 2024) involved ASA I-III patients (aged 18-75) undergoing ASR, (NCT05683522). Both groups received blocks pre-surgery: SOP block with 15 mL of 0.25% bupivacaine; combination block with 20 mL for CC and 10 mL for SCP. The primary outcome was 24-hour morphine consumption. Secondary outcomes included NRS scores, time to first opioid request, and complications. Quality of recovery-15 scores were also documented.

In this study consisting of 61 patients (SOP: 31, CC+SCP: 30), no significant difference was found in morphine consumption, pain scores and QoR scores (p>0.05). Time to first analgesia request was shorter in the SOP group than CC+SCP group (490±393 vs 280±256 minutes, respectively; p: 0.015),(Table1-2). Hemi-diaphragmatic paralysis was not observed, however, Horner syndrome was noted in only 1 patient in SOP group.

Ultrasound guided SOP block and CC+SCP blocks were similar in terms of analgesic consumption and pain scores in ASR, and the number of complications was almost non-existent. The SOP group caused less forearm motor block and may be more operator-friendly due to its single injection.

Thoracic outlet syndrome (TOS) is a rare condition characterized by compression of neurovascular structures in the thoracic outlet. Surgical decompression is indicated when conservative treatments fail. This study compares the efficacy and safety of regional anaesthesia (RA) combined with spontaneous breathing versus general anaesthesia (GA) for TOS surgery (Fig.1).

A retrospective comparative study was conducted on 68 patients undergoing trans-axillary first rib resection for TOS. Patients were divided into GA (29) and RA (39) groups. RA involved supraclavicular brachial plexus (SBP) (Fig. 1) and pectoral nerves (PECS II) blocks with deep sedation. Pain scores, opioid consumption, and perioperative outcomes were analyzed.

Postoperative pain was significantly lower in the RA group in the recovery room (median NRS 0 vs. 2, p = 0.0443) (Fig.2). Intraoperative fentanil and remifentanil consumption were significantly lower in the RA group (96.15 ± 62.18 mcg vs 312.07 ± 92.24 mcg and 73.13 ± 132.75 mcg vs 390.57 ± 390.71 mcg, respectively; p< 0.05). Postoperative morphine was required only by 18% of patients in the RA group (vs. 55% in GA group). RA was associated with shorter surgical times and reduced nausea and/or vomiting. Moreover, in RA group fewer intraoperative lung injuries occurred due to lung collapse during spontaneous breathing (0% vs. 41%; p < 0.001) (Fig.3). Length of hospital stay was also shorter in the RA group.

RA combined to spontaneous breathing significantly reduced opioid consumption and surgical times, facilitating surgical maneuvers and decreasing complications, compared to GA. Further studies are warranted to validate these findings.

Chronic postoperative pain remains a significant barrier in patients who have undergone shoulder surgery. We evaluated the predictors of chronic pain following shoulder arthroscopy.

This was a retrospective, observational study of patients who underwent shoulder arthroscopy at Ankara University between 2012 and 2017. This study was approved by the local ethics committee. Telephone contact was established with 178 patients who met the study criteria. Demographic data, comorbidities, preoperative interscalene block application, intraoperative opioid use, and records of postoperative patient-controlled analgesia were obtained by reviewing patient files. Upon contact, each patient's psychological state and pain level were assessed.

An interscalene block was administered to 33 (18.5%) of the patients, while patient-controlled analgesia was provided to 97 (54.5%). The analgesic method of 48 patients’ were not achieved from the records. Chronic pain was identified in 92 patients (51.7%). Body weight, comorbidities, and the combined use of opioids and non-opioids were found to be significant risk factors (p=0.024, 0.016, and 0.010, respectively) for chronic pain. Multivariate Logistic Regression analysis revealed that the risk of chronic pain in patients with comorbidities and combined opioid-non-opioid use was 9.27 times higher than in those without comorbidities. In the presence of comorbidities, the risk of chronic pain was found to be 7.18 times higher in patients who did not use a combination of opioids and non-opioids.

This study indicates that higher body weight, the presence of comorbidities, and the use of both opioids and non-opioids are significant predictors of increased chronic postoperative pain following shoulder arthroscopy.

Accidental Dural Puncture (ADP) is the unintentional rupture of the dura mater. ADP-associated Post-Dural Puncture Headache (PDPH) can cause considerable morbidity. The aim of this retrospective study was to identify the incidence of ADP and PDPH following epidural placement for labour analgesia.

Cases of ADP and PDPH were identified retrospectively from MN-CMS(The Maternal and New-born Clinical Management System).Further cross reference was undertaken using a written departmental communications book. Analysis of this data was carried out using Microsoft Excel.

Between 1st July and 31st December 2023, 1262 women received an epidural for labour analgesia. ADP was identified in 5 women. Two of these women developed PDPH. The incidence of ADP and ADP-related PDPH were 3.9 and 1.58 per 1000 cases respectively. Six additional cases of PDPH after labour epidural analgesia were identified without having a recognised dural puncture, from a written departmental communications book. The overall incidence of PDPH was therefore 6.3 per 1000 cases. Six women required an epidural blood patch, one woman required a second blood patch. PDPH resolved without blood patch in two women.

The observed incidence of ADP complicating epidural anaesthesia is within published ranges. The incidence of post-dural puncture headache after ADP was lower than anticipated. Interestingly three of the women with documented ADP, showed no signs of PDPH. PDPH occurred in the absence of documented ADP.

This comparative study aimed to assess the efficacy and safety of ultrasound-guided caudal anesthesia versus blind caudal anesthesia for subumbilical surgery in pediatric patients.

Pediatric patients undergoing subumbilical surgery were prospectively included and divided into two groups: ultrasound-guided caudal anesthesia and blind caudal anesthesia. Primary outcomes evaluated included block placement success rate, onset and duration of sensory and motor blockade, analgesic requirements, and perioperative complications.

The study included 40 patients, with 20 in each group. Ultrasound-guided caudal anesthesia showed a significantly higher success rate of block placement (p < 0.001), faster onset of sensory and motor blockade (p < 0.05), and longer duration of analgesia (p < 0.05) compared to blind caudal anesthesia. Postoperative analgesic requirements were significantly lower in the ultrasound-guided group (p < 0.001). There were no significant differences in perioperative complications between the two groups.

Ultrasound-guided caudal anesthesia was superior to blind caudal anesthesia for subumbilical surgery in pediatric patients. It provided higher success rates, faster onset, longer duration of blockade, reduced analgesic requirements, and comparable safety. Ultrasound guidance should be preferred for caudal anesthesia in this patient population.

A significant portion of patients experience posterior pain after hip surgery. Vermeylen et al. established a new approach to alleviate this pain by the development of the posterior pericapsular deep-gluteal block (PPD). Since the relatively recent development of this approach, the clinical characteristics lack further research. It is hypothesized that the volume of the injection plays a crucial role in determining the success of the block. In this cadaveric study, the spread of different volumes of dye is compared.

Two fresh-frozen human specimens (specimen 821 & 823: both men, 91 and 81 years old respectively) were obtained from the human body donation program of the university and included in the study. Using ultrasound guidance, 5 ml, 10 ml, 15 ml or 20 ml of dye (10% latex, 1.5% methylene blue 10 mg/ml and 88.5% water) was injected in the targeted area. Each of the four hip regions were dissected. Dimensions of the dye spread were obtained.

The sciatic nerve was affected by dye above the branch of the nerve going to the quadratus femoris (NQF) in two of the four injections. The injected volume of the dye doesn’t seem to matter. The sciatic nerve was only stained with the injection of 20 ml and 5 ml of dye. Following PPD injection, none of the hip regions showed staining of the NQF itself.

There was an inconsistent staining of the sciatic nerve, which was unrelated to the injection volume. The effectiveness of the PPD block requires further anatomical and clinical validation.

Genicular nerve block is defined as infiltration of the sensory branches innervating knee joint before they enter knee capsule. Inconsistency in the terminology and origin of genicular nerves in the literature may be related to variations in anatomical descriptions. Aim of this study was to provide the dissection of genicular nerves and to evaluate efficacy in postoperative analgesia in arthroscopic anterior cruciate ligament(ACL) repair by ultrasound guided blocking of identifiable nerves.

In the first phase, four cadaveric knees were dissected. N.obturatorius, n.ischiadicus, n.peroneus communis and n.tibialis branches were found. Genicular nerves of knee capsule were demonstrated. In the second stage, 60 patients aged 18-75 years who were planned for ACL operation were randomly divided into two equal groups. Group G; preoperative genicular block was applied from four different injection points, while Group K received no block. All patients were operated under general anesthesia. Postoperative fentanyl IV patient-controlled analgesia was administered. Postoperative VAS scores at rest and motion, analgesic drug consumption and side effects were measured at 1-6-12-24 hours.

Superior medial and lateral genicular branches originated from n. tibialis, inferior lateral branches originated from n. peroneus communis, inferior medial branches originated from n. tibialis and branches originated from n. saphenus participated in sensory innervation. In our study, additional analgesic was required in Group K at 1-6-24 hours. Postoperative VAS values were lower in Group G at all times.

Knee capsule has a very rich nerve network. Genicular block should be considered as a good postoperative analgesia option after ACL repair surgery.

Even though the robotic-assisted approach to the abdominal cavity is less invasive than conventional laparotomy, postoperative pain may still affect early recovery after gynaecological surgery. Transversus Abdominis Plane (TAP) block has been studied for robotic gynaecological surgery with inconsistent results. We performed a review of the literature to evaluate the effect of TAP block in postoperative pain following robotic-assisted gynaecologic surgery.

We searched PubMed, Embase and MEDLINE using the key words gynaecology, surgery, robotic, postoperative and pain. We investigated postoperative pain scores, amount of analgesia required, and adverse events associated with the block.

Four studies were included in our review. Pain scores at 4 hours and at 7 days postoperatively were lower in patients that had received TAP block when urogynaecological procedures were studied. Reduced opioid use was noted at 24, 48 and 72 hours after the surgical procedure for robotic-assisted hysterectomy when liposomal bupivacaine was used for the TAP block. However, no difference in pain scores, opioid consumption or nausea/vomiting at 24 hours was found when plain bupivacaine was used for the TAP block.

TAP block doesn’t seem to offer any advantage for gynaecological surgery in terms of postoperative pain relief and opioid consumption unless liposomal bupivacaine is used. It seems to reduce pain scores after urogynaecological procedures but further studies are needed.

The brachial plexus (BP) branching pattern is highly variable. Due to their clinical implications, the study determines the BP variants and interconnections (ICs) between its trunks, lateral and medial cords (LC and MC), and peripheral nerves. Coexisted arterial variants are also described.

Twelve (7 male and 5 female) formalin-embalmed donated Greek cadavers (72-91 years of age) were dissected. After written informed consent, the donated cadavers were bilaterally dissected at the neck, axilla, and arm by following a well-established dissection protocol.

Various ICs were identified in 70% of the cases. Special findings were: 1. The musculocutaneous nerve (MCN) and the lateral root (LR) of the median nerve (MN) were found to have atypical right-side formations and course. 2. On the right side, the MCN was absent, the anterior arm muscles were supplied by the MN, and contralaterally, the MCN-MN IC existed. 3. a right-sided MN bifurcation after its formation 4. a right-side LR duplication, along with an MCN duplication and an IC between LC and MC 5. a right-side IC of the MCN-MN 6. a right-side IC of the LR with the MR and the BP medial cord (MC) 7. 3 cases of IC between median and ulnar nerve (MN-UN) 8. 1 case of IC between intercostobrachial nerve (ICBN) and RN

Most of the findings were consistent with the literature. Knowledge of these variants is important during surgical, therapeutic, and diagnostic upper limb procedures, especially for anesthesiologists who perform peripheral nerve blocks.

Cardiac surgery influences respiratory morbidity through multiple mechanisms. In our institution, the anesthesia team uses classic protective ventilation strategies. Optimization of ventilation could still be possible. The primary endpoint is to evaluate the potential for alveolar recruitment, in patients undergoing cardiac surgery, at 2 times (after intubation, and after cardiopulmonary bypass (CPB), by collecting the values of pulmonary compliance and the R/I ratio. The secondary endpoint is to determine if there are statistically significant differences, in terms of respiratory and hemodynamic parameters between patients with a ratio to patients who are above or below the median.

This is a prospective and observational study. The patients studied are undergoing cardiac surgery. Patients' perioperative data were recorded. With a maneuver we calculates the R/I ratio and the recruited volume and the compliance of the recruited lung. The ratio of this compliance to the compliance at low PEEP gave the recruitment-to-inflation ratio.

Intermediate results show significant differences with improvement of compliance 10 min after recruitment. The median R/I was 1.58 +/- 0.67 before CPB and, 1.15 +/- 64 after CPB indicating a potential for recruitment. P/F values did not show a statistically significant increase, which could reflect good pulmonary vasoconstriction in pulmonary atelectasis. Recruitment maneuvers, with moderate PEEP, are well tolerated in our patients.

R/I ratio highlights a potential for recruitment in our cardiac surgery patients. This test is hemodynamically well tolerated and could differentiate patients who are candidates for an increase in PEEP. A larger study is needed to confirm these results.

Thirty percent of cancer patients experience chemotherapy-induced chronic neuropathy (CIN), which is still an unmet clinical challenge because current standard treatments have significant side effects and are not very effective. Because they are highly expressed in the nervous system, cannabinoid receptors offer a promising target for CIN treatment. Although the plant itself might not have the same analgesic effect as an active pharmaceutical substance, its use as an adjuvant to traditional analgesic treatment would be justified given its reduced adverse effects when administered orally. The aim of this study was to evaluate the in vivo efficacy of an EU-GMP-certified Cannabis sativa L. in a paclitaxel-induced chronic neuropathy (PIN) mouse model.

To evaluate the analgesic effects on PIN in mice, a standard pain test battery was used, consisting of two thermal sensitivity tests and one pressure test. The experimental study was performed in accordance with the European Directive 2010/63/EU and has been approved by the university’s Research Ethics Committee (no. 47/17.02.2021) and authorized by the National Sanitary Veterinary and Food Safety Authority (no. 34/07.04.2021).

The tested product exhibited a variable analgesic effect across the three tests used, with the effect being more noticeable in the pressure stimulus test.

It is challenging to translate cannabis into the clinic, but finding novel ways to reduce CIN could significantly enhance the quality of life for millions of cancer survivors. Although more research is required to confirm these results, the existing findings are encouraging.

The use of adjuvants like dexamethasone, clonidine, and bicarbonate helps prolong the duration of the effect of local anesthetics (LA). Only a few studies are available about the pH dependency, magnitude, or timing of crystal precipitation effects for various LA adjuvant combinations. The study aimed to quantify the crystallization effect of the addition of varying doses of dexamethasone and dexmedetomidine to a combination mixture of 0.75% ropivacaine and 2% lignocaine with and without epinephrine.

The LAs and adjuvants tested in this study were a combination of equal volumes of ropivacaine 0.75% with plain lignocaine 2% or lignocaine 2% with epinephrine (5mcg/ml) to a total volume of 20 ml. Varying doses of dexamethasone 2mg, 4 mg, and 8 mg were added to this LA mixture and were observed for crystallization. Subsequently, dexmedetomidine in a dose of 50 mcg was added to each of the LA + dexamethasone mixture to assess for crystallization. pH of all the solutions was noted.

Crystallization occurred in the 2% lignocaine and 0.75% ropivacaine group with all doses of dexamethasone and dexmedetomidine 50 mcg. The crystallization was seen with in 5 minutes dexmedetomidine was added. The crystallization occurred at a pH of 4.5. The crystallization wasn’t seen in 2% lignocaine and epinephrine with 0.75% ropivacaine groups, with either adjuvant, pH being 6.5.

Crystallization in local anesthetic solutions occurred with dexamethasone starting at 2mg dose. Dexmedetomidine appeared to expedite crystallization when added as a second adjuvant. The crystallization could be pH dependent occurring at a lower pH.

Aimed to identify whether the use of peripheral nerve blockade (PNB) pre-traumatic limb amputation reduced long-term opiate requirements. Evidence suggests that epidural anaesthesia may reduce post-surgical pain. Data to show the longer-term effects PNB has on opiate use is limited.

This was a retrospective observational study. Patients who underwent orthopaedic limb amputation between 21/07/2020 and 19/10/23 were included. Anaesthetic charts, notes and community prescriptions were reviewed to assess pre-admission, discharge, and present opiate prescription.

69 patients identified. 72% had a PNB (single shot or infusion), 28% did not. 42/69 (61%) patients were prescribed an opiate prior to admission for amputation.

This observational study did not show that PNB pre-amputation reduces opiate prescription at or beyond discharge. The data highlights that fewer (62% vs 81%) patients who were on opiates pre-admission were given a PNB compared to those who were not prescribed opiates pre-admission. In those who had a PNB, 88% of patients taking opiates pre-admission were discharged with opiates compared to 63% of those not on a pre-admission opiate. Results suggest that pre-admission opiate use may not always be used as a considering factor for PNB in current practice. Limitations to this study include a small cohort size, unrecorded indications for opiate prescriptions and unclear reasons as to why patients did not receive PNB. Further work to establish whether PNB reduces long-term opiate use is needed. A study where patients (PNB vs non-PNB) are monitored at set time intervals post amputation to assess change in opiate requirement would be useful.

This study aimed to standardize postoperative pain management in major outpatient surgery by developing evidence-based protocols, as recommended by the PROSPECT guidelines. The study compared the effectiveness of these protocols with the traditional liberal management of postoperative pain prescribed by surgeons for patients undergoing inguinal hernia surgery at MAS.

A sample of 60 ASA I and ASA II patients undergoing inguinal hernia surgery at MAS was collected. Thirty patients followed a protocol-based home analgesic regimen of Paracetamol 1 g alternated with Tramadol 75 mg and Dexketoprofen 25 mg every 8 hours for 3 days. The other thirty patients received a surgeon-prescribed regimen of Paracetamol 1 g alternated with Ibuprofen 600 mg every 8 hours, with Tramadol 50 mg as rescue analgesia for 5 days. Pain levels were assessed using the VAS scale at 24 and 48 hours, and adverse effects were recorded.

The protocol group had a mean VAS score of 2.3 points at 24 hours, compared to 4.1 points in the conventional treatment group. At 48 hours, the protocol group scored 1.2 points, while the control group scored 2 points. The Student's t-test indicated a significant reduction in postoperative pain for the protocol group at both 24 and 48 hours (p<0.05).

Analgesic guidelines based on the developed protocol offer a significantly more effective alternative for managing postoperative pain than the liberal analgesia prescribed by surgeons in patients undergoing inguinal hernia surgery at MAS.

The management of perioperative analgesia in clinical practice is often distressing and full of challenges. Opioids are recommended as perioperative analgesic treatment for patients undergoing orthopedic surgery, but there are not widely use resulted from adverse effects. This study aimed to assess the efficacy and safety of Crisugabalin for perioperative analgesia in patients undergoing orthopedic surgery.

Subjects (18-75 years) scheduled for elective orthopedic surgery under general anesthesia, which was expected to take no more than 4 h, postoperative analgesia expected to last >24 h were randomized to preoperative 40mg Crisugabalin and postoperative placebo (40mgPre), preoperative 60mg Crisugabalin and postoperative placebo (60mgPre), preoperative and postoperative 40mg Crisugabalin (40mgPre&Post), preoperative and postoperative 60mg Crisugabalin (60mgPre&Post) and placebo. The primary endpoint was total morphine dose in the 24 h postoperative period.

A total of 235 subjects from 20 institutions were randomized to receive Crisugabalin groups and placebo group (figure 1). Morphine consumption within 24 h after surgery was 9.9±8.2mg, 10.3±8.8mg, 9.7±10.1mg and 15.7±12.1mg for Crisugabalin 60mgPre, 40mgPre&Post, 60mgPre&Post and placebo group, showing statistical significance for Crisugabalin groups versus placebo group (P=0.0239, P=0.0261 and P=0.0076, respectively, table 1). Except that the incidence of dizziness and somnolence in Crisugabalin groups were higher than in the placebo group, there were similar types and incidence of TEAEs related to these groups, and most TEAEs were mild to moderate, and spontaneously resolved without necessitating interventions.

The trial demonstrated that Crisugabalin reduced postoperative opioid consumption, and well tolerated for the treatment of perioperative analgesia in patients undergoing orthopedic surgery.

Accidental dural punctures (ADP) during neuraxial analgesia/anesthesia pose significant concerns in obstetrics, prompting post-dural puncture headache (PDPH) in 50-88% of cases. Understanding the determinants of post-ADP length of stay (LOS) is crucial for optimizing care. This study aims to identify such determinants in parturients.

This retrospective study included all patients diagnosed with ADP after neuraxial labor analgesia at our institution, between October 2013 and 2023. All relevant data were obtained from medical records’ review.

Seventy-four ADP were identified. The mean post-ADP LOS was 4.69 days, exceeding the average LOS for uncomplicated deliveries at our institution. Moderate-to-severe PDPH was associated with prolonged hospitalization (mean LOS: 4.91 vs 3.43 days, p<0.05). Interestingly, epidural blood patch (EBP) administration did not reduce the LOS. However, when headache onset occurred within 48 hours after ADP, early EBP (<48 hours after ADP) was linked to earlier discharge (mean LOS 3.5 vs 5.11 days, p<0.05). Premature birth, ASA classification and cesarean delivery were associated with extended hospitalization. These factors were not associated with PDPH development or severity. Age, BMI, and technical aspects related to neuraxial approach showed no association with LOS.

PDPH-related factors, as headache intensity and early EBP in parturients displaying early symptoms, were associated with the hospitalization duration. Although there’s evidence in the literature that an early EBP may increase the need to repeat the procedure, our study didn’t demonstrate that. Determinants of obstetric post-ADP LOS are multifactorial and also depend on obstetric factors. Managing ADP-related hospital stays is complex and further research is needed.

This study investigates the therapeutic potential of Transcutaneous Electrical Acupoint Stimulation (TEAS) in enhancing gastrointestinal recovery and alleviating postoperative acute pain among laparoscopic total hysterectomy

From May 2022 to May 2023, 120 patients undergoing laparoscopic total hysterectomy were studied. The TEAS group (T group) received preoperative, intraoperative, and postoperative electrical stimulation, while the control group (C group) did not. Outcomes measured included gastrointestinal function, postoperative nausea and vomiting, postoperative acute pain，patient-reported outcomes on the GSRS and VAS, and plasma levels of gastrin and motilin analyzed using ELISA.

Relative to the C group, the T group exhibited a statistically significant acceleration in postoperative gastrointestinal recovery markers, including earlier occurrences of first flatus, defecation, bowel sound resumption, and initial solid food consumption. Additionally, this group demonstrated a notable reduction in the incidence rates of PONV within the initial six hours post-surgery. Furthermore, a marked decrease in both GSRS and VAS scores was observed at 2 hours and 1 day postoperatively, indicating an alleviation in gastrointestinal symptoms and pain. This clinical improvement was accompanied by a significant increase in plasma gastrin and motilin concentrations, suggesting a physiological enhancement in gastrointestinal functionality post-TEAS intervention(P<0.05).

TEAS group's significant improvement in gastrointestinal recovery reduced PONV and alleviated postoperative acute pain, suggesting TEAS's potential as a beneficial intervention in laparoscopic total hysterectomy.

Co-relation between USG measured epidural depth with actual depth together and BMI

94 patients undergoing gynaecological procedures were recruited and study was done with supervision of professor from radiology.

Problem 1: Co-relation between measured depth (with the ultrasound) and the actual depth (with the needle) together with BMI- correlation can be identified by Scatter Matrix three variables (file attached as number 1) Correlations Needle depth USG BMI Needle depth 1 USG .668 1 BMI .643 .535 1 Also all the correlations are statistically significant at 95% level of confidence with reported p value <0.0001 Problem 2: Does BMI affect the needling A procedure of mediation analysis has been attempted which explains the casual relationship between two measuring methods that is being influenced by BMI. Underlying model ( image attached) Results: Direct and total effects Coeff s.e t Sig(two) c .6008 .0830 7.2395 .0000 a 3.2417 .4793 6.7634 .0000 b .0321 .0213 1.5085 .1363 c' .4968 .1073 4.6309 .0000 Indirect effect (ab) and significance using normal distribution Value s.e LL95CI UL95CI Z Sig (two) Effect .1040 .0714 -.0359 .2439 1.4572 .1450 Bootstrap results for indirect effect (ab) Data Mean s.e LL95CI UL95CI Effect .1040 .1040 .0849 -.0557 .2967 Number of bootstrap re samples: 1000

This is statistical significance (p value <0.001) of total effect with positive (0.6008). Though the effect size of BMI is of same direction (0.1040) it is not statistically significant as can be observed from the p-value >0.05 (0.1450)

Point-of-care ultrasound (POCUS) has emerged as a valuable tool for all regional anaesthetists to help diagnose relevant complications of anaesthesia and guide perioperative management. POCUSCLUB was organised as a comprehensive education and training programme to improve competency in and encourage the use of perioperative POCUS.

A 5 session schedule was designed to teach the A-E of POCUS: A - airway, B - lung, C - cardiac, D - regional anaesthesia blocks for ICU and E - FAST and gastric. POCUSCLUB sessions lasted one hour encompassing an interactive presentation followed by hands-on scanning on live models. A pre- and post- course questionnaire survey was utilised to assess the competency of trainee and consultant anaesthetists in POCUS.

In the pre-course survey, we found that most anaesthetists used POCUS for vascular access, regional anaesthesia and US guided invasive procedures. However, 80% indicated they did not feel competent in using POCUS in perioperative situations and the most wanted to learn to use ultrasound for airway, lung, cardiac and abdominal FAST. 100% of participants agreed POCUSCLUB would be useful in learning how to integrate POCUS effectively into clinical practice.

Perioperative POCUS is a critical skill for regional anasthetists. Our comprehensive POCUSCLUB training programme can help bridge the gap between desire and achievement of competency in POCUS.

The hospitalization of elderly patients for urgent surgeries has seen a significant increase in recent years due to demographic aging. These fragile patients are more vulnerable to perioperative anxiety, delirium, and postoperative pain. The objective of our study is to evaluate the effect of different dosages of melatonin on perioperative anxiety, perioperative stability, and the prevention of postoperative delirium in elderly patients admitted to theorthopedic department of CHU Fattouma Bourguiba for osteosynthesis of a fracture of the upper extremity of the femur.

This is a prospective, randomized, double-blind study conducted in the operating rooms of the orthopedic surgery and traumatology department of CHU Fattouma Bourguiba, Monastir. We included 123 patients over 65 years old admitted for pertrochanteric fracture,divided into three groups: control group M0, group M3 (3 mg of melatonin), and group M6 (6 mg of melatonin). We evaluated perioperative anxiety, sedation, delirium, and postoperative pain.

The majority of patients were female with a mean age of 78.8±9.2 years, ranging from 65 to 101.The majority of patients had an ASA score of 2 (74%). A comparison of the three study groups, after premedication revealed: A lower anxiety score (VAS) in the M3 and M6 groups than in the control group. A lower level of sedation in the control group. Better hemodynamic stability in the M6 group. Analysis of postoperative data showed:A dose-dependent analgesic effect of melatonin, with the M6 group being superior to the other groups.

Melatonin has demonstrated numerous benefits in theperioperative management of elderly patients.

Spontaneous intracranial hypotension (SIH) is caused by a cerebrospinal fluid (CSF) leak without a specific history. The symptoms of SIH include orthostatic headache accompanied or not by symptoms such as neck pain, nausea, and vomiting. EBP is considered the treatment of choice when SIH does not respond to conservative treatment, and if symptoms do not improve, EBP can either be repeated or targeted to the leakage site. However there are some cases where repeated EBP does not show any improvement and are difficult to treat

In the described case, symptoms persisted despite repetitive targeted EBP, and thus, we performed a simultaneous two-site EBP procedure. Briefly, with a needle placed simultaneously at C7/T1 and T11/12 levels, 8 ml and 12 ml of autologous blood were injected, respectively. Subsequently, symptoms improved without any side effects

After 2-site simultaneous EBP, the symptom improvement was well maintained, and the patient was discharged without any side effects. Brain CT images obtained a month after simultaneous targeted EBP confirmed complete absorption of the bilateral fluid collection

2-site simultaneous EBP can be an alternative treatment option in cases of spontaneous intracranial hypotension refractory to conservative therapy and traditional epidural blood patch.

Patients undergoing elective Total Knee Arthroplasty (TKA) often experience significant postoperative pain, hindering early mobilisation and rehabilitation. Motor-sparing regional analgesia techniques, such as the Infiltration between Popliteal Artery and Capsule of the Knee (IPACK) block, aim to reduce pain, opioid use, and muscle weakness. However, the analgesic efficacy of the IPACK block remains unclear. This study investigates whether Adductor Canal Block (ACB) with IPACK reduces postoperative opioid consumption at 24 and 48 hours post-TKA compared to ACB with local infiltration of anaesthetic (LIA).

This retrospective cohort study analysed 130 elective TKA cases at a regional NSW hospital over one year that received ACB + IPACK (n=71, 54.6%) and ACB + LIA (n=59, 45.4%). Linear regression analysis was then used to determine postoperative mean oral morphine equivalent daily dosage (OMEDD) at 24 and 48 hours, adjusting for age, sex, chronic opioid use, neuraxial anaesthesia, peripheral nerve infusion, and adjuvant analgesia.

This study demonstrated significant reductions in mean OMEDD at 24 hours with IPACK + ACB compared to ACB + LIA (IPACK + ACB: Mean OMEDD=54.8 mg; ACB + LIA: Mean OMEDD=76.4 mg, p=0.02). At 48 hours, no clinically or statistically significant reduction in OMEDD was observed.

This study found that the addition of the IPACK block to ACB provides superior analgesia in the first 24 hours post-TKA when compared with ACB and LIA. These results support incorporating the IPACK block into standard care to reduce opioid consumption and associated adverse effects.

When conducting spinal anesthesia, pregnant patients and patients with lower limb injuries may have difficulties taking the optimal position. This study investigates whether the posture of the trunk, flexing of the lower limbs and tilting of the head affects the interspinous distance.

This cross-sectional study was conducted on 25 healthy adult volunteers with their consent and approval by the Institutional Ethics Committee of Shizuoka general hospital (No. SGHIRB#2023051). We performed lumbar ultrasonography in the left lateral position to measure the interspinous distance at the L2/3, L3/4 and L4/5 interspace, in seven different positions: P1: straight-back with bilateral lower limb extension, P2: straight-back with unilateral lower limb flexion, P3: straight-back with bilateral lower limb flexion, P4: P3 with head tilted forward, P5: forward bending with bilateral lower limb flexion, P6: forward bending with unilateral lower limb flexion, P7: forward bending with bilateral lower limb extension. Using P1 as the reference, each position was compared using linear regression analysis with statistical significance set at p<0.0071 after Bonferroni adjustment for multiple comparisons.

Positions that significantly affected the widening of the interspinous distance were P5 at the L2/3, L3/4 and L4/5 interspace (P<0.001, P<0.001, and P<0.001, respectively) and P6 at the L2/3 and L4/5 interspace (P<0.003, and P<0.003, respectively). Whereas the tilting position of the head did not affect the interspinous space.

In healthy adults, forward bending with even unilateral lower limb flexion affects widening of the interspinous space, while tilting of the head does not have an impact.

This prospective observational study aimed to explore the frequency and risk factors of rebound pain (RP) in patients treated with multimodal analgesia and intravenous dexamethasone following peripheral nerve block (PNB) for anesthesia and multimodal analgesia in orthopedic surgeries.

This study included patients who received preoperative PNB from August 2022 to December 2023. All patients received a standard multimodal analgesia regimen and intravenous dexamethasone. Motor and sensory block durations, RP severity and frequency were measured for the first 24 h post-PNB using a semi-structured questionnaire. RP was identified as acute postoperative pain within the first 12-24 h after sensory blockade resolution. The severity of RP was determined through the rebound pain score. Contributing risk factors (patient, surgical, or anesthesia-related) to the development of RP were investigated.

Following PNB worn off, RP developed in 107 out of 386 patients (27.72%). The following were identified as independent risk factors for RP: patient age, with an adjusted odds ratio (AOR) of 2.323 and a 95% confidence interval (CI) of 1.379–3.915; the use of bupivacaine in combination with lidocaine or prilocaine (AOR: 2.128, 95%CI: 1.206–3.754); preoperative pain (AOR:2.751, 95%CI:1.345–5.623); bone surgery (AOR:1.761, 95% CI:1.025–3.023); and the duration of the surgery (AOR:2.785, 95%CI:1.510–5.137).

With standard multimodal analgesia methods and intravenous dexamethasone, the incidence of RP can be lessened. By correctly identifying RP risk factors, we can establish preventative strategies that target changeable factors, leading to optimized use of PNB, decreased RP incidence, and improved results.

We aimed to prospectively compare the effects of Oblique Subcostal Transversus Abdominis Plane (OSTAP) block and Transmuscular Quadratus Lumborum (TQL) block on postoperative analgesia and quality of recovery in gynecological laparoscopic surgery, using a randomized controlled, double-blind approach. We hypothesized that TQL block would provide effective analgesia in gynecological laparoscopic surgeries, thereby reducing need for analgesics.

68 patients undergoing gynecological laparoscopic surgery were prospectively evaluated and randomized into two groups: OSTAP group (n=34) and TQL group (n=34). Following the block, anesthesia induction was administered. Postoperative rest and movement VAS scores, consumption of paracetamol and tramadol within the first 24 hours, time to first requirement of paracetamol and tramadol, nausea-vomiting, mobilization and discharge times, preoperative-postoperative 24th hour QoR-15 scores were recorded. Patient-surgeon satisfactions were measured with a 5-point Likert scale.

In TQL group, significantly lower VAS scores were observed at rest and in movement at the 6th hour and in movement before discharge (p=0.019, p=0.004, p=0.023, respectively). However no differences were found between the groups at other time intervals. The number of patients requiring paracetamol, time to first requirements of paracetamol and tramadol, total doses of tramadol were similar between groups. Conversely, total dose of paracetamol and number of patients requiring tramadol were significantly higher in OSTAP group (p=0.002, p=0.006, respectively). There were no differences in nausea-vomiting, need for antiemetics, preoperative-postoperative QoR-15 scores, discharge times and patient-surgeon satisfactions.

TQL block has been shown to be more effective than OSTAP block in managing postoperative pain, underscoring its importance in multimodal analgesia protocols.

Multiple sclerosis (MS) is a common chronic, immune mediated demyelinating disorders with a preponderance towards the female population.Here we made an attempt to analyse the literature to create a systematic review with regards to nerve blockade (central and peripheral) and its effects in patients with MS.

Search for RCTs and case-series studies were carried out using MEDLINE, EMBASE and cochrane CENTRAL trials register. RefWorks system was used to de-duplicate the studies collected.

Eight RCTs were found, five were decided to be of inadequate strength to analyse further. We also found no strong case series reports to be added to the study. Regarding Central Neuraxial Blocks (CNBs), low dose epidural is considered safer as compared to spinal anaesthesia (Bajaj et al). Spinal anaesthesia is considered to be a relative contra-indication (Cimenti et al). Furthermore, Lumbar plexus blocks and para-vertebral blocks were noted to have prolonged duration in patients with MS while Peripheral Nerve Blocks (PNBs) is thought to be relatively safer as compared to CNB (Schneider 2005).

Despite compelling evidence suggesting that spinal anaesthesia should be avoided in certain situations, low-dose epidurals present a relatively safer alternative when CNBs are necessary. It is important to consider that some plexus blocks, like the paravertebral block, may have a prolonged duration in patients with MS. PNBs are generally safer, although the anaesthetist must be aware that approximately 5% of patients with MS may have peripheral nerve involvement. In all cases, a thorough discussion with the patient and meticulous documentation are essential.

The hospital serves as the center for orthopedic cases in the country and is in constant pursuit of means to safely and efficiently cater to large volume of surgeries on a daily basis. Clavicle surgery has always been performed under general anesthesia in the institution. This is often associated with longer turnaround time, moderate to severe post op pain, increased opioid consumption and prolonged stay in the recovery room. Recent advances in the center have enabled clavicle surgeries to be executed solely under interscalene and superficial cervical plexus blocks (ISB+SCPB). This retrospective study presents the outcome of the technique done in a tertiary orthopedic hospital.

Upon approval of Institutional Ethics Review Board, chart of patients who underwent clavicle surgery from 2021-2023 were reviewed. Forty two patients received ISB+SCPB as sole anesthetic for open reduction, internal fixation (ORIF) of clavicle. Outcomes were described.

Vital signs of patients were all stable pre-, intra- and postoperatively. No adverse outcomes were reported. Mean duration of sensory and motor block was 19 and 17.42 hours respectively. No patient required rescue opioid dose for severe pain in the 1st 24 hours.

Interscalene and superficial cervical plexus blocks provided adequate anesthesia and enhanced postoperative outcome. The combined techniques may be considered as alternative to general anesthesia for clavicle surgeries. Larger prospective studies are recommended.

Peripheral nerve blocks (PNB), either single shot injection or continuous catheter infusion, are increasingly used in total (hip/knee) joint arthroplasties (TJA). A recent meta-analysis concluded equivalence between single shot and continuous catheter infusion PNBs in immediate perioperative analgesia. However, comparative data on longer term outcomes such as chronic opioid use is scarce. Using national US data we aimed to address this evidence gap.

After institutional review board approval, we utilized US Merative Marketscan commercial claims data (n= 223069 TJAs from 2017-2021). Three groups were compared: 1) no PNB, 2) single shot PNB, and 3) continuous catheter infusion PNB. Risk of chronic opioid use (Table 1) was compared between these 3 groups using a multivariable inverse-probability-of-censoring weighting model; we report odds ratios (OR) and 95% confidence intervals (CI).

Chronic postoperative opioid use was found in 12.3%, 15.1% and 15.5% of patients without PNB, with single shot PNB, and with continuous catheter, respectively. Our multivariable model showed no difference in chronic opioid use between single shot and continuous catheter PNB use. However, our pairwise comparisons did identify that single shot (versus no) PNB is associated with slightly higher odds of chronic opioid use: OR 1.02 95% CI 1.01-1.03.

Our analysis of large data shows no significant difference on chronic postoperative opioid use between single shot and continuous PNB patients. Hereby, we have added to the evidence with more long-term outcomes.

Non-perfused chicken breast models have been utilized to determine the relative lesion size across the various radiofrequency (RF) electrode types (1). To date, no research has been conducted on comparison of lesion sizes of three commercially available probes (standard, three-tined and cooled) utilizing the same RF generator manufacturer.

Each probe underwent RF at the time and temperature settings they are commercially suggested for (i.e. standard probes for 90s at 80°C, three-tined probes for 120s at 80C, and cooled probes for 150s at 60°C. Lesioning was performed with Avanos Pain Management and Cooled Radiofrequency Generators. The lesions were created and measured using internally approved standard test method that underwent test method validation (TMV). Each lesion was measured for width and height with calibrated calipers under a 0.5X lens microscope, following previously published methodology (1). The minimum lesion data set was n≥30, where the sample mean is normally distributed and statistical significance can be recognized (2).

Mean lesion sizes and standard deviations are reported in table 1. Lesions created by standard RF probes were elliptical in shape, whereas cooled and three-tined probes had a more spherical shape with more distal projection from the probe tip.

Mean lesion volume for cooled probes increased as probe active tip (AT) size increased. The standard RF probe created a larger lesion than the smallest cooled probe, but a smaller lesion when compared to the other cooled probes. The three-tined probe created lesions significantly larger than the standard RF probe, despite having a smaller active tip size.

Quadratus Lumborum Block III(QLB-III) and Ilioinguinal-Iliohypogastric (II-IH) nerve blocks can be utilized for postoperative analgesia after cesarean operations. The aim of this prospective randomized study is to evaluate the postoperative analgesic effectiveness of QLB-III and II-IH blocks in patients undergoing cesarean delivery.

In this study, 70 patients were analyzed. Patients undergoing cesarean delivery under spinal anesthesia were divided into two groups after the operation, and trunkal blocks were applied. Group QLB (n=34) received bilateral QLB-III block with 20 ml of 0.25% bupivacaine under ultrasound guidance. Group II-IH (n=36) received bilateral 20 ml of 0.25% bupivacaine under ultrasound guidance. Tramadol consumption, NRS scores were recorded at 2, 4, 8, 12, and 24 hours.

Total tramadol consumption in the first 24 hours postoperatively was significantly lower in the QLB-III group. When the resting NRS (rNRS) and dynamic NRS (dNRS) values were compared between the groups, there was no significant difference at all time points. However, intragroup analyses revealed that in the QLB-III group, rNRS values at 24 hours were significantly higher than those at 2 hours. In the II-IH group, both rNRS and dNRS values at 24 hours were significantly higher than those at 2 hours.

In the postoperative period following cesarean delivery, both the QLB-III block and the II-IH block resulted in low NRS scores within the first 24 hours. Since the QLB-III block is associated with lower opioid consumption compared to the II-IH block, we believe it can be preferred for postoperative analgesia in cesarean deliveries.

Chronic neck and arm pain (CNAP) is a common problem in the adult population with a typical 12-month prevalence of 30% to 50%, that has a substantial impact on health care and society, remaining a debilitating problem among adults. The current orientation of conservative therapy includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, muscle relaxants or short course of opioid pain medication, all of which lead to a temporary improvement in a majority of patients. If conservative therapy does not provide symptomatic relief, selective nerve root PRP injections can be used. The aim of this study is to evaluate the efficacy of PRP treatment in patients with CNAP. The rationale of using PRP is that they promote an inflammatory response that will lead to healing

40 patients with CNAP were injected 2 mLs of autologous platelet plasma rich via selective nerve root injection, under ultrasound guidance into the affected area. The patients were followed up using NRS and ODI (before / after). PRP was obtain and prepared from patients own blood under strict aseptic technique. 24 mL of blood was centrifuged for 2 minutes at 3450 rpm, the resulting 12 mL were again centrifuged at 3550 rpm for 5 minutes, the resulting 2 mls from the lower part of the tube were administered next to the affected nerve root, with 22G needle using ultrasound guidance.

Patients showed improvement in their scores at the 3 months follow up with no complications.

PRP injection is an effective therapy for cervical pain.

Background and Aims: Achieving rapid onset of surgical anaesthesia after a popliteal sciatic nerve block remains a challenge, which this study aimed to determine using a twin subparaneural injection below its divergence with alkalinized lignocaine

After ethical approval 20 ASA I-III patients scheduled for elective foot and ankle surgery, under an ultrasound-guided popliteal sciatic nerve block (PSNB), were recruited for this non-randomized study of intervention. All patients received two separate injections into the individual subparaneural compartments of the common peroneal (CPN) and tibial nerve (TN) below the divergence, each with 14.5 ml of 1.5% lignocaine and 0.5 ml of 8.4% sodium bicarbonate. To achieve this, the subparaneural compartment of the sciatic nerve was initially distended with normal saline at its divergence. Sensory and motor blockade was assessed using a numeric rating scale (0-100; 0=anaesthesia) and Likert scale (0-2; 0=paralysis) respectively. Time to achieve complete anaesthesia (sensory score 0/100 and motor score 0/2) and duration of sensory-motor blockade were the primary and secondary outcomes, respectively.

The median [IQR] time to complete anaesthesia was 10[5-15] min for the CPN and 15[10-25] min for the TN and it was effective for surgery in all patients studied. The median[IQR] duration of self-reported sensory motor blockade was 7.4 [5.9-9.7] hours.

An USG subparaneural PSNB when performed as two separate injections below the divergence of the sciatic nerve, with alkalinized lignocaine, produces surgical anaesthesia within 15 minutes. We believe this is the fastest onset-time reported for a PSNB in the literature.

Rheumatoid Arthritis (RA) is a chronic autoimmune inflammatory joint disease affecting approximately 0.5-1% of the world population, with a higher prevalence in women. In addition to physical limitations, RA imposes restrictions in psychological, emotional, and social aspects of patients' lives. Effective management and coping often require high levels of self-efficacy. Psychological disorders, are prevalent in RA cases. However, the relationship between personality traits and self-perceived capabilities among diagnosed women remains understudied. This study aimed to (1) examine the relationship between anxiety, depression, quality of life, and self-efficacy in women with RA; and (2) compare these factors between women with RA and healthy counterparts.

The study included 248 women, 104 with RA and 144 without any background diseases, aged 18 and above. The questionnaire covered sociodemographics, Beck Depression Inventory (BDI), State and Trait Anxiety questionnaire, SF12 Quality of Life questionnaire, and Self-Efficacy questionnaire.

Depression correlated significantly with quality of life (rp(104)=-0.559, p<0.01) and self-efficacy (rp(104)=-(0.536, p<0.01)) in women with RA. Self-efficacy was related to anxiety (rp(104)=-0.230, p<0.05). However, no distinct correlation was found between anxiety levels and overall quality of life in women with RA. Depression levels were higher in women with RA (t(246)=-5.331, p<0.05), while self-efficacy levels were lower (t(186.075)=8.189, p<0.05). No significant differences were found in anxiety levels and overall life quality between the groups

Depression and self-efficacy significantly differ between healthy women and those with RA. In women with RA, depression affects life quality and self-efficacy, while anxiety relates to self-efficacy.

Popliteal sciatic nerve block performed in lateral position usually requires a change in position for the patient. This is time consuming and may cause discomfort to the patient. This prospective study compared patients' preference and peri-operative outcomes in supine position via medial approach to the sciatic nerve and lateral position via lateral approach to the nerve.

50 patients from Ng Teng Fong General hospital (NTFGH) who were undergoing popliteal sciatic nerve block with or without sedation from July 2022 to February 2024 were recruited for the study and randomised to either receive the block in supine or lateral position.

This study showed that there were significantly more patients in the supine group preferring to be in supine position during the block with p-valve <0.001. 45.8% of patients who had the block performed in lateral position preferred supine position instead. There was no significant difference in the peri-operative outcomes or duration taken for block completion. Most patients preferred to be in the supine position for popliteal sciatic nerve block as it was more comfortable.

Performing the block in supine position is non-inferior to performing it in lateral position in terms of safety, efficacy and efficiency profile.

Therapeutic virtual reality (VR) can alleviate pain and anxiety (Colloca 2020, Terzulli 2022, Terzulli 2023). This study aimed to assess VR hypnosis (VRH) on pain and anxiety during heat stimulation in healthy volunteers.

French ethic committee approved the study on 04/02/2020. After written consent obtention, heat nociceptive stimulations (45°C/25s, 46°C/20s and 47°C/10s) were applied to the wrist of 22 healthy volunteers with a contact probe (QST.Lab, Strasbourg, France). The control period (without VRH, CTRL) was compared with the VRH period (HypnoVR Biofeedback®, VRH). Data on demographics, anxiety (STAI-trait/80), suggestibility (Stanford/12), pain intensity (Visual analog scale VASi/10), unpleasantness (VASu/10), and state anxiety (STAI-State/80) before CTRL (State 1), between CTRL and VRH (State 2) and after VRH (State 3), were collected.

Significant reductions were observed in VASi (4.7 ± 2.3 vs. 3.8/10 ± 2.5, p=0.002), VASu (5.3 ± 1.9 vs. 3.7/10 ± 2.5; p < 0.001), and anxiety State 3 vs. State 2 (26.6/80 ± 9.9 vs. 31.7 ± 10.9; p < 0.001), whereas not between State 1 and 2 (p>.05). Responders to VRH (i.e., decreased pain intensity > 10%, non-responders as those with no change (-10 to +10%), and inverse responders as those with an increase > 10%. For intensity, proportions were 59%, 32%, and 9%, respectively. For unpleasantness, proportions were 77%, 14%, and 9%, respectively.

HypnoVR Biofeedback® reduced pain intensity, unpleasantness, and anxiety during heat stimuli. However, 9% of volunteers responded negatively, it is comparable with our previous study2. Further studies on patients are needed to correctly characterize these patients.

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

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

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

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

INTRODUCTION: Lateralized spinal anesthesia is based on the difference in density of the anesthetic solutions compared to the CSF which defines their baricity. OBJECTIVE: The aim of our study is to evaluate the anesthetic technique of unilateral spinal anesthesia in an outpatient setting. Namely the time of appearance of the block, the success rate, the recovery profile of spinal anesthesia as well as the hemodynamic state. For this we used levobupivacaine at 0.5% hypobaric as a drug.

MATERIALS AND METHODS: We conducted a prospective randomized study, including 44 patients proposed for orthopedic surgery since January 2016. They were divided into three groups: Group A: a series of 13 patients received 8 mg of 0.5% hypobaric levobupivacaine intrathecally 2.5 sufentanyl. Group B: a series of 17 patients received 10 mg of levobupivacaine 0.5% hypobaric intrathecally 2.5 sufentanyl. Group C: a series of 14 patients received 12 mg of levobupivacaine 0.5% hypobaric 2.5 sufentanyl.

RESULTS: In table n°1 and n°2 summarizes the demographic data, 44 patients were included, the patients were comparable for age, sex, ASA score and BMI. The type of surgery was noted as well as the duration of the intervention. Note when there were no cases of transient radicular irritation syndrome, No bladder globus or post-spinal headache in our series.

CONCLUSION: Unilateral spinal anesthesia is of great interest for ambulatory practice: reliability, simplicity, less toxicity, compared to multiple blocks, associated with rapid recovery of fitness for the street, particularly due to early ambulation.

Subarachnoid block has been extensively practiced for infraumbilical surgeries.Intrathecal adjuvants like Fentanyl, Midazolam are added to local anaesthetic Bupivacaine to improve the quality of neuraxial block and prolong the duration.To investigate the potentiation of analgesic effect by adding adjuvant Midazolam to local anesthetic Bupivacaine and adjuvant Fentanyl combination in subarachnoid block to the patients undergoing lower limb orthopedic surgery.

Subjects were randomized to two groups according to the anaesthetic medication used. Group A received 2.8 ml of hyperbaric 0.5% Bupivacaine with 0.5 ml (25μg) of Fentanyl and 0.2 ml of Normal saline; Group B received 2.8 ml of hyperbaric 0.5% Bupivacaine with 0.5 ml (25μg) of Fentanyl and 0.2 ml (1 mg) of Midazolam. The onset and duration of sensory and motor blockade, duration of post-operative analgesia were recorded in a case record form. Statistical significance defined as p-value < 0.05 and confidence interval set at 95% level.

In this study, mean onset time of sensory block were 4.57±0.3 minutes and 4.29±0.1 minutes in group A and group B respectively. The mean onset times of motor block between two groups were 7.70±0.4 minutes and 7.35±0.3 minutes in group A and group B respectively. The mean (±SD) duration of analgesia was 307.3±11.3 minutes in group A and 364.9±16.6 minutes in group B. The comparison between outcome variables of two groups showed very highly significant (p<0.001) difference.

Addition of intrathecal Midazolam to Bupivacaine and Fentanyl combination potentiates the analgesic effects in terms of prolonged duration of analgesia and sensory- motor block.

The results of using a laryngeal mask airway (LMA) to ensure airway patency during thyroidectomy are satisfactory.

Prospective randomized clinical trials were conducted in 96 patients operated on for nodal euthyroid goiter (patient’s informed consent have been obtained). Induction was carried out by bolus intravenous administration of fentanyl ), midazem and propofol . LMA was established after induction in spontaneous breathing. Administration of propofol continued as an intravenous infusion at a dose of 5 -7 mg/kg/hour until the end of the surgery. The adequacy of anesthesia was assessed by clinical observation, by studying the variables of the standard monitoring (ECG, heart rate, BP,SpO2), BIS monitoring, acid base balance (ABB) and arterial blood gas (ABG) composition and the level of cortisol in the venous blood.

Clinical observation showed the adequacy of anesthesia. After induction, fluctuations in peripheral circulation were not pronounced, since LMA administration is not traumatic. The surgical stage of anesthesia was achieved quickly, with a smooth course and hemodynamic stability without respiratory depression. The depth of anesthesia was easily controlled by a change in the dose of propofol drip. All quantitative indicators of standard monitoring (BP, heart rate, SpO2), ABG composition and cortisol level in venous blood were change in statistically acceptable range. LMA was removed after the completion of the surgical intervention with adequate spontaneous breathing. Complications associated with the use of LMA were not observed.

Anesthesia with the use of LMA with preserved spontaneous breathing is an adequate method of anesthesia in thyroid surgery.

Tourniquet use in orthopedic surgeries aids in creating a bloodless surgical field but can lead to complications, notably pain. This study primarily aimed to assess the effectiveness of subanesthetic ketamine in preventing tourniquet-induced hemodynamic responses during arthroscopic knee surgery of adult patients.

This was a retrospective, analytical, observational, cohort type of an epidemiological study conducted at a tertiary care center from March 2023 to November 2023. Forty five adult patients who had arthroscopic surgery of the knee were evaluated to assess the effectiveness of subanesthetic intravenous ketamine for tourniquet pain relief, 21 had received ketamine and 24 did not. The endpoints of this study were changes in the vital signs (systolic blood pressure and heart rate) and use of intraoperative fentanyl.

There was a significant decrease in the heart rate of ketamine group at the 45 and 60-minute intervals. In contrast, systolic and diastolic blood pressure measurements did not show noticeable disparities among the groups at most time points, indicating that ketamine's impact on blood pressure was minimal. The overall usage of intraoperative fentanyl was low in both groups, with a minor increase observed in the non-ketamine group in the later stages of surgery. However, this observed pattern did not achieve statistical significance.

A subanesthetic intravenous ketamine dose contributes to a significant reduction in the heart rate during arthroscopic knee surgery, without substantially impacting blood pressure or the need for additional opioid such as the fentanyl.

Phantom limb pain (PLP) remains a challenging condition that is common after limb amputation and has a high prevalence among wounded military personnel. This study evaluates a comprehensive approach that combines long-term peripheral nerve blocks with systemic pharmacologic interventions to address this complex phenomenon.

A randomized trial design was adopted to evaluate the efficacy of two primary treatment modalities: Method 1, consisting of regional anesthesia applied twice at 72-hour intervals, supplemented by fentanyl patch applications; and Method 2, involving prolonged perineural blockade via intraneural catheters over six days. Participants included wounded military personnel experiencing PLP, with interventions tailored based on individual patient characteristics and the anatomical level of amputation.

The study included 26 participants, with 73.1% (n=19) undergoing Method 1 and 26.9% (n=7) receiving Method 2. Initial pain scores averaged at 7.1 ± 2.1 on the Visual Analog Scale (VAS), with notable reductions observed post-treatment (3.2 ± 1.6 for Method 1 and 4.1 ± 2.6 for Method 2). Method 1 demonstrated superior efficacy in pain reduction and improvement in sleep quality compared to Method 2.

The integrated treatment approach, combining systemic pharmacotherapy with targeted regional anesthesia, significantly alleviates PLP in wounded military personnel, enhancing their quality of life. Method 1 showcased greater effectiveness, underscoring the importance of personalized and adaptable pain management strategies in military medical care. Further research is warranted to optimize treatment protocols and explore the long-term benefits of such integrative approaches.

The prospect of “hearing and seeing everything” in the operating theatre can be a source of great anxiety and discomfort for the patient leading to dissatisfaction and possibly failure of the regional anaesthesia technique.(1) iPads have been shown to be an effective audio-visual distraction aid to minimise anxiety and improve patient satisfaction. (2) Our project reviews whether the use of a VR headset would as effective as using iPads during invasive procedures performed under regional anaesthesia.

Following informed consent, we prospectively collected feedback from 5 patients undergoing Orthopaedic surgery under regional anaesthesia with the virtual reality headset Oculus Quest 2. Feedback from the Anaesthetist was also recorded.

None of the respondents reported to being uncomfortable or anxious at any time. 1 respondent felt the headset to be heavy. All the respondents said they would recommend this to other patients. Challenges faced were unreliable hospital wifi, inability to manage case and setup when solo Anaesthetist on the list and difficulty to adjust the display settings particularly when the patient was lying flat.

Although bespoke medical VR solutions exist, they are expensive and limited in what distraction they provide. Here we used a consumer device and played youtube videos of the patient’s choice. Hence, more economical. We observed high satisfaction with audio-visual distraction using a VR headset, but technical challenges of the specific headset limited utility. A new headset, Quest 3 has now been released which we believe will overcome some of the technical challenges .

Spontaneous intracranial hypotension (SIH) is an increasingly recognized condition. While SIH was rarely diagnosed in the past, it is now acknowledged as an important cause of headaches. Spinal dural cerebrospinal fluid (CSF) leaks cause SIH, and in 20% of cases, they are associated with a meningeal diverticulum in the region of the nerve root.

A 51-year-old, male patient, referred to neurology presenting with an 8-month long history of postural headache, tinnitus and vertigo, was admitted for diagnostic work-up and subsequently diagnosed with SIH. Magnetic resonance imaging showed signs of intracranial hypotension and several meningeal diverticula in the region of the nerve roots spanning from the lower cervical to the lower thoracic level (C7-T10) –see Figure 1. After ruling out overt leakage of CSF from other locations, a causal association between the meningeal diverticula and SIH was assumed.

Being non-responsive to previous conservative measures (bed rest, abundant oral hydration and caffeine 600mg/day), an epidural blood-patch (EBP) was requested to the anaesthesiology team. An EBP was performed at T9-T10 level with 20 ml of autologous blood, without complications.

The result was complete resolution of symptoms in a few hours, with asymptomatic ambulation and hospital discharge within 24 hours.

Neuropathic pain (NP) arises from lesions or diseases affecting the somatosensory system, with increased neuronal activation and ectopic discharges. In pediatric oncology, may be due to chemotherapeutic agents, as structural, post-surgical lesions, phantom limb syndrome, autoimmune and degenerative neuropathic diseases. Diagnosis in children can be difficult due to the variety of symptoms and requires multiple therapeutic strategies for management. Treatment of NP in children follows similar principles to those in adults, but doses are usually moderate and rarely increased to the maximum for maximum effectiveness.

An independent review was carried out by the authors in the databases with a subsequent meeting, where the articles that were found were presented and a consensus was reached on the articles to be included. The objective of this article is to conduct a narrative review of the existing literature on the treatment of cancer-related neuropathic pain in pediatric population.

Thorough evaluation and effective pain control play pivotal roles in enhancing the well-being and health outcomes of this poblation. If initial treatments prove ineffective, interventional therapies should be accessible as alternative options. Different scientific societies advocate for employing a multimodal approach encompassing pharmacological, physical, and psychotherapeutic interventions, tailored to individual needs. The overarching objective should be to enhance the quality of life for the patient.

Neuropathic pain is frequently seen in pediatric cancer patients, but is often overlooked and inadequately treated with ineffective treatments. Treatment of neuropathic pain in this population involves a comprehensive evaluation along with the use of pharmacologic, interventional, and nonpharmacologic approaches.

The ilioinguinal/iliohypogastric nerve block (IINB) is a well practiced regional anesthesia (RA) technique for inguinal surgeries in children. IINB is considered as effective as caudal block for peri-operative analgesia. Ultrasound guidance (USG) of IINB offers advantage of direct visualization of nerves, helps decreasing the volume of local anaesthetics (LA) used and thus, increases safety. This study aimed at proving efficacy of USG IINB, using low volume of LA, defining the surrounding anatomical structures in children.

We studied various scientific papers, meta-analysis and review articles published between 2005-2023 related to IINB in paediatric unilateral inguinal surgeries like orchidopexy and inguinal hernia repair. The conventional fascial pop techniques using large volume of LA are replaced with precise visualization of nerve and needle during USG IINB, enabling use of ultra low volume of drugs to achieve high quality block.

"RA always works provided you put the right dose of the right drug in the right place." This adage reflects the true reality of RA. Accurate placement of LA around IIN in children is seldom possible using landmark technique. USG ensures the right place between internal oblique and transversus abdominus, avoiding injury to adjacent structures. The distance between skin-IIN is 5-10mm, and between IIN-peritoneum is around 3-5mm in children. Using USG IINB , an effective block can be achieved using volume of 0.25% Levobupivacaine as low as 0.075ml/kg.

The use of USG IINB enables the administration of ultra low volume of LA at correct fascial plane with maximum efficacy in children undergoing inguinal surgeries.

Posterior quadratus lumborum block (QL2), has been implemented as a part of multimodal analgesia in postoperative pain relief after abdominal surgery. However, cadaveric studies did not demonstrate an effective dye spread to the thoracic paravertebral space, the target are for mechanism of action. We aimed to determine, the spread of injectate in QL 2 blocks

In 2 cadavers donated through body donation programme for science studies, QL2 injections were performed, with 30ml of 0.1% methylene blue dye. On the 2nd day, cross-sections were executed in one cadaver and open dissections was performed in the other. The cross-sections and the open dissections were examined in detail for the diffusion of the dye by anatomist and co-anaesthesiologist not involved in injection

The cross-sections revealed spread of the dye in following planes : Posterior surface of QL, Lateral to QL, Lateral in transverses abdominis plane (TAP plane). Open dissections depicted dye spread in soaking the ilio-inguinal, ilio-hypogastric and the sub-costal nerves. Exploring the lumbar plexus did not reveal staining of nerves. However, the visceral and parietal peritoneum was stained

The mechanism of action of QL2 is probably through the lateral diffusion in the TAP plane and a caudal spread in the visceral plane.

Continuous femoral triangle block (c-FTB) is used to extend postoperative analgesia after total knee arthroplasty (TKA). However, catheter tip migration can occur during infusion and may fail to provide good postoperative pain relief. In this study, we retrospectively compared pain scores and the incidence of catheter tip migration during c-FTB in patients undergoing TKA between catheter-over-needle and self-coiling catheter.

This retrospective study was approved by the institutional IRB (study number: 20231109-2). We analyzed the data of patients who underwent TKA with c-FTB between March and December 2023. A CON (E-Cath, PAJUNK, Geisingen, Germany) or self-coiling catheter (Pain Clinic Set, Hakko, Chikuma, Japan) was inserted using an in-plane approach with a short-axis view for c-FTB. Patients also received IPACK block and local infiltration analgesia. Appropriate catheter tip position was confirmed by injecting a small amount of saline under ultrasound immediately and 24h after surgery. The incidence of catheter tip migration and postoperative pain scores were compared between the two types of catheters.

Data of 47 patients (19 and 28 patients for CON and self-soiling catheter, respectively) were analyzed. At 24h after surgery, catheter tip migration occurred in 68.4% and 7.1% of the patients using CON and self-soiling catheter, respectively (p<0.001). Postoperative pain scores did not differ between the two catheters.

The incidence of catheter tip migration was lower for self-coiling catheter compared with CON when used for c-FTB. Postoperative pain level was similar for two types of catheters.

The ambulatory pathway for upper limb trauma surgery at cork University Hospital has incorporated ultrasound guided regional anaesthesia as the principal anaesthesia modality. The anaesthesia model of care incorporates: single shot axillary brachial plexus block (AxBPB); perioperative dexamethasone; and postoperative multimodal oral analgesia. The aim of this service evaluation was to ascertain an objective assessment of patient experience.

A prospective audit was performed during March and April 2024. Thirty non-consecutive patients opportunistically sampled, undergoing ambulatory upper limb surgery under AxBPB were included. Patients were contacted by telephone 2 days postoperatively. Patient satisfaction was measured using a 6 point likert scale (0-5) to evaluate satisfaction with anaesthesia, analgesia and their overall experience with the ambulatory care pathway. A priori threshold score of greater than or equal to 4 was defined as the audit standard. Patient data was compared with historical non-paired controls (2022) to evaluate pathway performance over time under two tail Mann Whitney U test.

Median [range] satisfaction scores were 5 [4-5], 5 [3-5], 5 [3-5] for anaesthesia, analgesia and overall ambulatory experiences. When compared to historical controls (2022), no significant difference was found. P-value were 0.4913, 0.2151, 0.4913 in anaesthesia, analgesia and overall ambulatory experiences. No perioperative and post-operative complication noticed.

Patient satisfaction is high for this ambulatory upper limb soft tissue trauma pathway enhanced by regional anaesthesia. Patient satisfaction was similar to historical controls, suggesting sustainability of the pathway over time, notwithstanding changes in personnel frequently encountered in a university teaching hospital setting.

The role of peripheral nerve blockade (PNB) as part of a multimodal analgesic strategy continues to grow. Nerve damage is a feared complication of PNB for both patients and anaesthetists. Our project aimed to quantify the rate and severity of nerve injury following PNB in our district general hospital, alongside patient centred outcomes. Finally, we assessed the feasibility of a PNB telephone follow up service in our trust.

Single-shot nerve blocks over a 7-month period were logged. Patients were contacted 48 hours to 14 days post-procedure, where a questionnaire was administered. We collected data on neurological complications, patient satisfaction, and the patient experience of PNB and the follow up process.

221 blocks were logged, of which 187 met the criteria for follow up, with successful follow up in 69% of patients. Fourteen patients required ongoing follow up due to persisting sensory neurological symptoms with 13 patients reporting complete resolution at 6 weeks (Figure 1). High patient satisfaction rates were reported post PNB, 91.5% reporting as satisfied or very satisfied, and 94% of patients reporting adequate information provided about their PNB (Figure 2).

We have demonstrated that PNB was associated with high patient satisfaction and a low complication rate. A comprehensive follow up system is labour intensive, and requires further input to implement permanently. The upcoming 8th National Audit Project from the Royal College of Anaesthetists (UK) will provide a greater pool of results and form recommendations from which to inform our future practice.

In addition, commonly known as neurotransmitters properties of some purines. Concentration of purines as neurotransmitters, may be correlated with characteristics of neuraxial block in spinal anesthesia.

We examined 30 pregnant women, who before starting spinal anesthesia for cesarean section was performed over the fence of venous blood, in the performance of spinal anesthesia (before the introduction of anesthesia) - fence CSF. Contents of purine bases was determined direct spectrophotometry in blood serum or cerebrospinal fluid in each of the purine metabolite wavelengths. Take into account the following characteristics of spinal anesthesia administered dose of mg spinal ropivacaine, speed of onset, depth and height of the spread of spinal block, the need for additional administration of intravenous analgesics and anesthetics.

Dose spinal ropivacaine correlated with blood guanine (r=0,73; p=0,040), hypoxanthine (r=0,82; p=0,013), adenine (r=0,77; p=0,023) and xanthine (R=0,71; p=0,046). Time of onset of adequate spinal block correlated with the blood guanine (r=0,89; p=0,003), hypoxanthine (r=0,85;p=0,008), xanthine (r=0,73; p=0,040), uric acid (r=0,78; p=0,022). Spinal block height correlated with blood guanine (R=0,74;p=0,035), and xanthine (R=0,71;p=0,048). Mothers with high-quality, adequate spinal block, which do not require the additional use of intravenous anesthetics differed from women with a low, not enough adequate spinal block, a lower concentration of guanine in blood serum (Mann-Whitney U Test, p=0,043)

The level of guanine in blood serum can be used to predict the quality of spinal anesthesia in obstetrics, possibly to define indications for preemptive use of combined spinal-epidural or general anesthesia instead of the single-stage single-dose spinal anesthesia.

Inadequate pain management after VATS lobectomies has been associated with significant morbidity. Thoracic epidurals (TEAs) have classically been the primary modality for post-operative analgesia. However, they are not without significant complications. We investigated if paravertebral blocks (PVBs) provide non-inferior postoperative analgesia while diminishing patients' risk of analgesia-related complications.

We performed an anonymized prospective chart review of 165 patients undergoing VATS lobectomies with a PVB or a TEA at Vancouver General Hospital with local health authority approval. Postoperative pain scores at rest and with activity, and total opioid consumption, were recorded in the PACU, and on postoperative days 0, 1, and 2. The frequency of hemodynamic and respiratory complications, Foley catheterization, nausea, pruritus, and drowsiness were recorded at the same time intervals. Data were analyzed using a linear mixed model. P-values less than 0.05 were considered to be significant.

65 patients received a PVB and 100 patients received a TEA, and the groups did not differ significantly for any studied demographic variable. We did not identify any points in patients’ post-operative courses where pain, at rest and with activity, and total opioid consumption differed significantly between the two patient cohorts. Patients who received TEAs had more complications than those with PVBs, with the greatest differences found in the incidence of hemodynamic complications, pruritis, and Foley catheterization.

PVBs offer non-inferior analgesia while providing a reduced incidence of analgesia-related complications relative to TEAs in patients undergoing VATS lobectomies. PVBs should thus be considered as an effective analgesic alternative to TEAs in these patients.

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

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

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

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

Focused Parathyroidectomy is usually performed under general anaesthesia. Cervical plexus block as a sole anaesthesia for parathyroidectomy has been rarely used. In this case series, we describe application of combined superficial and intermediate cervical plexus (ICPB)block in two high risk patients scheduled for focused parathyroidectomy.

First case fifty year old male with hyperparathyroidism ,motor neuron disease and inflammatory polyarthritis, on examination he had dysarthria, tongue fasciculations, absent gag reflex and poor effort tolerance. Second case was a forty year old female with hyperparathyroidism, hypertension, recurrent renal stones and recent history of recovery from typhoid fever. Due to high risk of prolong post operative mechanical ventilation in first case and in view of recent history of typhoid fever in second case regional anaesthesia was planned in these two cases. At the midpoint of sternocleidomastoid(SCM)),ultrasound guided ICPB was given with 8 mL of 0.5% ropivacaine(Fig-1).Through same entry point needle 8 mL of 0.5% ropivacaine was deposited to give a single point subcutaneous superficial cervical plexus block(Fig-2). Block was repeated on the other side as well.

In both the two cases, cervical plexus block provided excellent surgical condition with good postoperative pain relief.

Superficial and intermediate cervical plexus block can be considered as a sole anaesthesia technique for focused parathyroidectomy as it provide prolonged postoperative analgesia, reduce the requirements for opioid analgesics and early discharge after surgery.

Intrathecal opioid therapy is indicated for various types of pain. Prior to the implantation of a programmable pump, a trial test is required. There is no consensus on the best method for conducting trial. We present a patient combining basal infusion of morphine with boluses using patient-controlled analgesia (PCA).

45-year-old severe traumatic injury in right lower limb 15 years ago, 30 surgeries including supracondylar amputation. Neuropathic pain in the stump and severe nonspecific lumbosacral pain. Multiple previous treatments: nerve blocks, rehabilitation, prolotherapy, high-dose methadone and adjuvants, infusions of dexmedetomidine and lidocaine. Multiple hospital admissions. Placement of an epidural catheter with fentanyl and bupivacaine infusion provided relief. It was decided to perform an intrathecal morphine trial.

Day1: Intrathecal catheter placed at T8. Initial bolus of 0.2mg of morphine sulfate (1mg/mL), and the PCA pump was programmed with a 10-hour lockout period. Then 0.1mg morphine boluses was programmed with a lockout period of 4 hours. The patient used 3 boluses. Day2: Continuous infusion was programmed with the total dose used on the previous day (0.5mg),boluses of 0.1mg with a 4-hour lockout period. The patient used 5 boluses, achieving VAS 2 only mild difficult to start urination was detected. Day3: Continuous infusion of 1mg over 24 hours was administered, imitating the definitive pump. Excellent response was maintained. The catheter was removed and implantation of an intrathecal pump was programmed.

PCA imitates the functioning of the definitive implantable pump and is a satisfactory method for conducting the intrathecal morphine trial.

Pain management after head and neck cancer free flap reconstruction is complicated by the different sites of surgery; the primary cancer site and the donor flap site. Perioperative analgesia has moved towards multi-modal analgesia (MMA) and this technique has been endorsed by the Society for Head and Neck Anesthesia (1). Although the primary cancer site is not conducive to conventional regional anaesthesia (RA) techniques, the donor flap site is often harvested from peripheral limbs and RA can play a key component of MMA. The aim of this report is to describe our current intraoperative analgesic regimes for patients undergoing free flap (FF) reconstruction for head and neck cancer surgery.

This is a retrospective review of adult patients undergoing elective head and neck FF reconstructive surgery over an 8 month period (September 2023-April 2024) at a tertiary hospital (50-60 cases/year). Patients who underwent rescue FF or regional flaps were excluded.

28 patients received FF reconstruction surgery with 29 flaps (table 1). All patients received MMA adjuncts in combination with opioids, with a significant proportion of patients receiving RA after flap harvesting (table 2). The commonest RA technique performed targeted the femoral nerve, reflecting the most frequent flap harvested (ALT), with popliteal blocks used for fibula flaps (chart 1).

At our centre we demonstrated a high level of MMA, including RA, for patients undergoing head and neck cancer FF reconstruction. We advocate that “Plan A” blocks can be used as part of MMA to reduce perioperative opioids and their associated side-effects.

The provision of care by the medical team must have an immediate and positive impact on the health and safety of patients. It is increasingly important to rely on cooperative teams in the healthcare field due to the rising complexity and specialization of care and the general labor shortage. Aim:To study the pillars of communication and collaboration between anesthesiologists and paramedical staff using the example of the maternity ward and to identify the causes of poor communication among the obstetric care team.

This is a survey using two questionnaires: the first addressed to midwives and the second to anesthesia technicians working in level III maternity wards. It is a descriptive study conducted within the obstetrical units (delivery room and operating room) of four Tunisian university hospitals

Seventy-three midwives and sixty-eight anesthesia technicians responded to our questionnaires. The relationship with the anesthesiologist was satisfactory in 67.9% and 72.9% of cases, respectively. The two main causes of poor communication were workload and lack of organization in over 60% of cases. The implementation of a service protocol guiding the call of the anesthesiologist in critical situations improved communication among the different stakeholders and significantly reduced the response time to calls (p=0.034). The proposed suggestion was basic training for all healthcare personnel on communication through high-fidelity simulation sessions.

Our study suggests that midwives and technicians do not have sufficient knowledge of their scope of practice, and that workload and lack of organization are the major causes of poor communication.

Chronic low back pain (CLBP) can be challenging to treat, with superior cluneal neuralgia (SCN) often overlooked as a potential cause. Peripheral nerve stimulation (PNS) has emerged as a promising therapy for CLBP, including SCN. This case series presents the outcomes of six patients with SCN treated with temporary PNS.

Retrospective analysis of six patients implanted with the Micro Lead -SPRINT PNS System. Data included pain scores, opioid use, complications, and outcomes.

Patients experienced chronic SCN pain for a mean duration of 18 months before PNS. Various treatments were unsuccessful. PNS resulted in significant pain relief and functional improvement at 6 months follow-up. However, at the 2-year follow-up, it was challenging to contact the patients, given inconclusive results.

SCN entrapment is often overlooked as a cause of low back pain. Diagnosis requires a detailed history and physical exam. PNS has shown effectiveness in managing chronic pain conditions and provides an alternative when conservative treatments fail. PNS can be effective in managing SCN, leading to significant reductions in pain intensity and improvements in functional status. However, further research is needed to better understand the optimal patient selection criteria, long-term efficacy, and cost-effectiveness of PNS compared to other treatment modalities.

There is limited national guidance available on infection control measures for peripheral nerve blocks. We were aware of some variation in practice and conducted a survey to establish if local guidance should be developed.

A survey was generated using Microsoft Forms and circulated around our department via email. Respondents indicated their standard practice for single shot peripheral nerve blocks. There were 4 questions covering use of gloves, probe coverings, skin disinfectant and gel. Each question had a range of preset answers. All responses were anonymised.

A total of 38 responses were received (54% response rate). Results are detailed in Table 1 (preset answers without any responses were omitted). The majority of respondents use sterile gloves and probe covers (87%). The most commonly used skin disinfectant is 2% Chlorhexidine (76%). All respondents use individual sachets of gel rather than multidose dispensers.

Higher concentration (2%) Chlorhexidine is non superior to lower concentration (0.5%) preparations at reducing risk of infection and has a higher theoretical risk of neurotoxicity. The 2% Chlorhexidine also has a greater financial and environmental cost due to its integrated single use applicator. Whilst there are limitations with self-reported data, the survey demonstrates a relatively consistent approach to other infection control measures amongst our department. The results of this survey have been shared with the department. Local guidance is being developed to promote use of 0.5% Chlorhexidine for peripheral nerve blocks. We plan to audit practice in due course. National guidance would be welcomed to help further standardise practice.

Chronic pain caused by lack of blood flow is known as ischemic pain. Neurostimulation by causing a decrease of sympathetic output reduces vasoconstriction and improves blood flow. Parasympathetic stimulation has also been implicated in improving circulation in the extremities by causing arteriolar dilatation. We described a case of chronic pain and calcaneus skin ulcer due to an arteriovenous malformation (AVM) of the left calcaneus, resistant to surgical treatment and pulsed radiofrequency. The 53-year-old female presented with pain associated to heat sensation, pruritus, and allodynia in the left heel. The patient underwent endovascular embolization without relief. Pulsed radiofrequency and analgesic block of the left posterior tibial nerve provided temporary relief.

The implantation of a neurostimulator electrode parallel to the left posterior tibial nerve, next to the internal malleolus, under ultrasound guidance occurred without complications.

The interventions resulted in significant pain relief, with the maximum visual analog scale (VAS) decreasing from 8/9 to 1 with four hours of neurostimulation daily. The calcaneus skin ulcer underwent excellent evolution as shown in figure 1.

This case underscores the importance of a multidisciplinary approach in managing pain and cutaneous manifestations related to AVMs. Neurostimulation’s emerge as effective therapeutic options for AVMs neuropathic chronic pain, offering promising outcomes for patients resistant to conventional treatments.

Continuous peripheral nerve blocks (CPNB) provide prolonged postoperative analgesia. However, there are concerns about the high reported rates of block failure and catheter dislodgement. We analyzed the efficacy and incidence of block failure and catheter dislodgement in our clinical practice.

This retrospective study analyzed perioperative data up to the third postoperative day using electronic records of patients who received CPNB over a 7 months period in 2023. Data were collected and the following variables were analyzed: type of surgery, location of CPNB, details of insertion, sensory and motor block, opioid consumption, maximum Numeric Rating Scale (NRS) score, timing of catheter removal, incidence of catheter dislodgement and side effects.

A total of 137 CPNB were inserted: 72% interscalene, 12% popliteal, 9% costoclavicular, 4% femoral and 3% supraclavicular. Insertion-related issues were reported in 12% of the cases: technical difficulties (7%), catheter replacement for accidental removal (4%) or inadequate local anesthetic spread (1%). Efficacy of CPNB is shown in Table 1. The mean maximum NRS on days 0, 1, 2 and 3 were 1, 3, 2 and 3. Reported complications were: block failure and replacement (1%) and accidental dislodgement during the first 24 hours (4%). Side effects of interscalene catheters were: Horner syndrome (2%) and respiratory insufficiency (2%).

CPNB was effective to prolong the analgesia up to 3 days, although the opioid sparing effect tended to decrease over time. The reported complications, side effects and accidental dislodgement were lower than previously reported.

Pain is defined as “an unpleasant sensory and emotional experience”. Nowadays regional neuraxial blockade is commonly used, especially in orthopaedic surgery. The aim of our study was to evaluate patient experience post regional anaesthetic blockade in elective orthopaedic day case surgery.

Data was collected over a five-day period. Data collected included, grade of block performer, the block performed, technique used (landmark/ultrasound guided), injectate used, if the block was the sole anaesthetic technique or with a general anaesthetic, immediate post operative verbal pain score (0-10) and post operative analgesics required. Subsequently, patients were followed up 24 hours post-op to assess pain scores, time till recovery of motor function and overall patient satisfaction score (1-10). The study was approved by the local Ethics Committee.

Over the five-day period data from 15 upper-limb blocks were recorded. 10 out the 15 blocks were axillary, four interscalene and one supraclavicular. Levobupivacaine 0.5% was the most common injectate used. Nine patients had a pain score of 0 (average 1.3). At the 24-hour follow-up pain scores varied quite significantly (average 3.25). Importantly, most patients felt they received poor information on what to expect post block. This led to delays in taking prescribed analgesia, anxiety regarding motor weakness and uncertainty when and where to seek help. However, overall satisfaction scores ranged between 7-10.

Poor patient education post peripheral block negatively impacted patients pain experience and may have led to worse pain scores. To tackle this specific post regional anaesthesia leaflets were introduced and given to all patients post-operatively.

The anesthesia consultation is a preparatory stage for the surgical act, during which pre-anesthetic information is necessarily delivered to the patients. The objectives of this study are to evaluate the impact of pre-anesthetic information on perioperative anxiety, and to compare the effect of each information mode on this anxiety and on the desire for information.

This is a monocentric, prospective, randomized study, conducted over a period of ten months from February 2023 to November 2023 in the anesthesia outpatient department at first, then in the various operating rooms and hospitalization.

This study showed a higher level of anxiety in the STANDARD group compared to the other two groups (72.8%). A level of anxiety adapted to the situation more frequently found for the BROCHURE group (19%). The VIDEO group had the lowest level of preoperative anxiety. The desire for information was high for the STANDARD group (70.6%) then in the BROCHURE group (54.9%), the VIDEO group (50%) had the lowest level of desire for information. The majority of patients in the VIDEO group (66.9%) were very satisfied with the anesthetic procedure (p= 10-3). Patients in the VIDEO group were the most satisfied with the anesthetic information provided (64.6%) unlike the STANDARD (36.8%) and BROCHURE (45.1%) groups (p= 10-3 ).

The management of perioperative anxiety is an important pillar in anesthetic management. Anesthetic information in the form of video may reduce the rate of this anxiety, with levels of satisfaction with anesthesia and pre-anesthetic information higher than the standard anesthetic information

Gaming in virtual reality (VR) is regarded as a secure and efficient substitute for traditional pain management techniques. The usefulness and practicability of a VR game for frequent burn dressing changes were examined in our study.

A randomized clinical trial was conducted among burned children hospitalized in the pediatric surgery department. We included burned children aged 4 to 12 years requiring daily dressing changes for at least 10 days a week. . One group played an interactive VR game during the dressing change, while children in the other group had a dressing change every other day while sedated with Ketamine and Propofol for 10 days. Perceived pain was assessed using a numerical rating scale (NRS) from 0 to 10 for both groups and the satisfaction of parents and care givers was also assessed.

18 children were recruited for this study. The majority were male (2/1 ratio) with second-degree burns (91.4%). Children and caregivers in the VR group reported less pain from the 4th dressing change onwards. Children in the VR group reported a clinically significant (≥23%) reduction in overall pain, and the caregiver described no incidents or difficulties with dressing changes compared to subjects in the control group. Parent satisfaction with VR remained at high level during dressing changes over the 1-week period, with reported realism and engagement increasing over time. More than half of the children (54.5%) enjoyed playing the game and no difficulties.

VR should be considered as a nonpharmacologic companion for pain management during burn dressing changes

Multimodal analgesia is effective way to treat postsurgical pain. Routine Opiate use for acute pain management leads to delayed discharge and for enhanced recovery we need to reserve opiates for rescue analgesia. Liposomal Bupivacaine prolongs efficacy and duration of action and helps achieve Drink Rest Eat Analgesia Mobilise (DREAM) recovery post knee replacement . FDA license for Single-dose infiltration was given in 2011 and subsequently for Brachial plexus block , fascial plane, post surgical wound infiltration. In 2023 FDA approved Liposomal Bupivacaine for adductor canal block and sciatic nerve block.

Data collected from 20 patients who underwent Total knee replacement ( TKR ) with 20 mls 266 (mg ) Liposomal Bupivacaine injcted under USG guidance for nerve infiltration in Adductor canal and IPACK ( Posterior capsule) compared with 20 patients who underwent TKR with standard technique of plain Bupivacaine local infiltration .Both sets of Patients were also given central neuraxial blockade with 0.5% Hyperbaric Bupivacaine 2.5 mls. A reduction in cumulative pain scores and opiate consumption postoperatively were end points.

Treatment with Liposomal Bupivacaine met the primary endpoint demonstrating significant 0 to 96 hours compared with bupivacaine hydrochloride (P <.01). Moreover,it was associated with a statistically significant reduction in postsurgical opioid consumption through 96 hours (P <.01). Statistical significance was achieved for the percentage of opioid-free patients who received Liposomal bupivacaine as a Adductor canal block through 96 hours (P <.01).

Peripheral nerve block with liposomal bupivacaine provides superior analgesia to local infiltration. Enhanced recovery DREAM fulfiled by Liposomal Bupivacaine.

Peripheral nerve block applications are frequently preferred in ankle surgery. It has been shown that the use of dexamethasone as an adjuvant provides longer analgesia and less postoperative analgesic use (1,2). However, there is insufficient evidence regarding lower extremity surgery (1). The aim of our study is to compare the analgesic efficacy of adding dexamethasone as an adjuvant in lower extremity peripheral nerve blocks.

Patients were divided into two groups. Using USG-guided nerve demonstration and a 22 G 100 mm needle, the first group (Group D) received a femoral and popliteal sciatic nerve block using 19 ml of 0.5% Bupivacaine+1 ml of 4 mg dexamethasone solution. The other group (Group B) received a femoral and popliteal sciatic nerve block using 19 ml of 0.5% Bupivacaine+1 ml of 0.9% saline solution. The time to the first analgesic requirement, total analgesic usage in the first 24 hours, and VAS (visual analog scale) values in the first 24 hours were compared.

The amount of analgesic used in the first 24 hours was significantly lower in the group that used dexamethasone (Table 1). When the dynamic and resting VAS values at 6., 12., and 24. hours were examined, the VAS values were lower in the group that used dexamethasone (Table 2).

In peripheral nerve blocks applied using dexamethasone, less analgesic use and lower VAS values were observed. Consequently, we believe that the use of dexamethasone as an adjuvant in femoral and popliteal sciatic nerve block applications provides a more effective analgesic effect.

PSARP (Posterior Sagittal Anorectoplasty) surgery is a surgical procedure performed in children to correct anorectal malformations. After this surgical intervention, pain management is very important for children. Reports have emerged of rare cases of sacral erector spinae block (SESB). In the hypospadias operation, Aksu and Gürkan successfully performed SESB for postoperative analgesia.

This is a retrospective case series of patients who underwent PSARP surgery at a tertiary university hospital between 2019 and 2023, and underwent SESB for postoperative analgesia. We administered propofol (2mg/kg) , remifentanil (1 mcg/kg), and rocuronium (0.6 mg/kg) in anesthesia to the approved patients and operated on them in the pron position after entubation. After surgery, we administered 15 ml/kg of paracetamol intravenously to all patients. We recorded post-operative Flacc scores, analgesic consumption, and complications.

The scanning of anesthesia and pain follow-up forms revealed that 17 patients had undergone PSARP surgery. We observed ultrasound-guided SESB in 14 patients, 9 girls and 5 males, using 0.2% bupivacaine at 1 ml/kg. The average age of the patients was 20.64 ± 8.67 months, and their average weight was 12.14 ± 2.21 kilograms. Four patients received paracetamol intravenously at 10, 12, 14, and 16 hours after surgery. No patient should use opioids within 24 hours. Flacc scores remained low for 24 hours. (Table1)(Figure 1) There were no complications.

In anorectal surgeries, SESB may provide effective postoperative analgesia.

Apart from sub-Tenon's blocks fascial plane blocks do not achieve sufficiently reliable analgesia to be used as stand alone surgical regional anaesthesia. In theory, this is due to insufficient filling of fascial compartments. A misconception of the fluid mechanics relying on fast-injection bulk flow and diffusion instead of accounting for porosity, viscosity and slow creeping flow (viscous fingering) in compartments with extensive 2D but small height extension

Plane (n=5) and spherical (n=5) Hele-shaw cells with glycerol as highly viscous fascial sheath simulation betweeen solid phase and cling film. Single and triple outlet cannula used to breach cling film and inject 5 ml NaCL-solution over 30 seconds.

Slow injection induced viscous fingering with central zones of high flow and peripheral zones of fingering progression front slow flow instead of concentric extension of sodium solution. This "fractal" propagation front filled the 20cm x 13 cm compartment to a great extent and gave way to diffusion after cessation of injection. The same applied to spherical models. Fast injection favored bulk flow.

Viscous fingering may arise in slow-injection fascial block that maintain small height of the compartment. Given fluid mechanic determinants like porosity, viscosity ratio between LA and fascial sheath content and control of turbulence during injection, slow creeping flow inducing viscous fingering may fill fascial sheath compartments to a greater extent. These flow patterns need to be assessed in cadaver and volunteer studies, using MRI or 3 D ultrasound reconstructions and may favor slow injection/catheter techniques in fascial plane blocks.

For over forty years, anesthesiologists of the institution have safely practiced the trans-arterial axillary brachial plexus block (ABPB) with intermediate-acting local anesthetic for forearm and elbow surgeries of pediatric patients. Recently, cases of neglected and complicated fractures with long operative times were encountered more frequently. This has rendered the duration of previous technique inadequate and has led to cases of unplanned conversion to general anesthesia. Technological advances in the latter years have enabled practitioners to administer long-acting local anesthestic for ABPB under ultrasound guidance. This study presents the outcomes of ultrasound-guided ABPB on pediatric patients in a tertiary orthopedic hospital.

With the approval of Institutional Ethics Review Board, investigators reviewed the chart of patients aged 8-17 years old who underwent forearm and elbow surgery under ultrasound-guided ABPB using isobaric bupivacaine +/- lidocaine and adjuncts for the period of June-October 2022. Outcomes were described.

Forty five patients were included with an average age of 13.76 years, predominantly male (73.33%), majority classified as ASA I (88.89%). Average onset time was 26.44 minutes, with a mean duration of 15.87 and 19.91 hours for motor and sensory block, respectively. Eight patients (17.78%) required rescue medication for post-operative pain, while the majority (82.22%) did not. Long-acting local anesthetic was safely administered without adverse events. Vital signs remained stable.

Ultrasound-guided ABPB provided safe motor and sensory block with adequate duration for pediatric patients aged 8-17 years old who underwent upper extremity surgery, supporting its effectiveness in achieving anesthesia and post-operative pain control.

The use of radiofrequency techniques targeting genicular nerves has become a viable option for managing refractory knee pain. Radiofrequency ablation(RFA) and pulsed radiofrequency(PRF) applied to peripheral nerves have demonstrated efficacy in pain reduction. Technical challenges such as charred tissue formation and optimal electrode placement present hurdles to achieving optimal outcomes. A novel approach, CRFA offers the potential for more comprehensive denervation. The utilization of larger, spherical lesion shapes minimizes missing target nerves and allows for greater flexibility in approach angles. There is a potential correlation between lesion size and the magnitude and duration of pain relief. We present a patient with chronic refractory knee pain in whom CRFA provided long-term pain relief.

A 65-year-old woman suffering from chronic refractory knee pain unresponsive to multiple treatments, including analgesics, physical therapy and bilateral knee replacement. Five left knee PRF(42oC;600”) yielded temporary relief, while minor improvement followed right knee PRF and three RFA(80oC;180”) sessions (2016-2021). Two CRFA(60oC;150“) sessions were performed on the left knee and one on the right (2022-2024).

CRFA led to a dramatic decrease in pain (VAS 9-10/10 to 0/10 at rest and 2/10 at walking). Significant and sustained pain relief for more than a year after each treatment, with no reported complications.

Our findings support CRFA as a safe and effective treatment modality for knee pain management, with superior long-term outcomes compared to traditional RF techniques. However, recent literature highlights limited and conflicting evidence, necessitating further clinical trials with extended follow-ups to validate the efficacy and safety profile of CRFA.

Benign prostatic hypertrophy (BPH) is common in men over 50. Thulium Laser Enucleation of the Prostate (ThuLEP) is a minimally invasive technique for treating BPH. A disadvantage of ThuLEP is the length of the procedure, which requires appropriate anesthesia. Continuous Spinal Anesthesia (CSA) offers hemodynamic stability and unlimited time under anesthesia by use of intermittent boluses or by pump infusion. The aim of the study is to compare the two techniques.

A retrospective study was conducted in patients undergoing ThuLEP between January 2023 and March 2024. Patients were divided into two groups CSA-B, (N =12) and CSA-I, (N=8) who received intermittent boluses or pump infusion. The average age of the patients was 70 years, ASA class (II - IV). Intralong CSA catheter (Pajunk, GmbH) 25, 27 G was placed at L3-L4, L2-L3. In both groups an initial dose of 1 to 1.7 ml of Bupivacaine 0.5% was administered, followed by boluses of 0.3 - 0.5 ml of 0.5% Bupivacaine in CSA-B or anesthetic infusion with 0.7 to 1.0 ml/hour in CSA-I. Some patients were also sedated.

A significant difference was found in the duration of anesthesia (p=0.0365) and a non-significant difference in the total amount of local anesthetic (p=0.06) and hemodynamic complications (p=0.47) in both groups. Correlations between complications - duration and complications - total amount of anesthetic are inverse. The dose-duration correlation is directly proportional.

CSA provides hemodynamic stability through both techniques of anesthetic administration in patients undergoing ThuLEP. Тhe infusion technique is preferred for a longer procedure.

Blunt thoracic trauma accounts for 10-15% of trauma admissions in the UK, with rib fractures complicating two-thirds of cases. Non-operative management is common in district general hospitals, necessitating a multidisciplinary approach to ensure healing and prevent complications. We aimed to evaluate rib fracture management practices at Lister Hospital and identify areas for improvement.

We retrospectively reviewed electronic records of patients admitted with "rib fractures" over a 5-month period (15/09/2022 – 17/02/2023, Cohort 1). Findings were used to develop a rib fracture pathway, which was implemented and reassessed over a 6-month period (01/09/2023 – 29/02/2024, Cohort 2).

Rib fracture admissions occurred every 2-3 days (118 patients), average hospital stay of 12 days. Easter scores increased from 7.8 (1-17) to 11.1 (4-27), indicating increased tendency to non-operative management. Timely referrals to pain teams were made (>80% of cases), but analgesia optimisation was needed in 22-35% of patients. Time to anesthetist review averaged 11.6 hours (range <30 minutes to 48 hours). Use of regional analgesia techniques increased from 30% to 62%, with decrease in epidural rates (45% to 15%), increase in paravertebral (36% to 65%) and erector spinae plane infusions (9% to 19%). Rates of PCA (morphine/fentanyl/oxycodone) were 22%. Critical care admissions decreased from 7% to 4%.

Key improvement areas include multidisciplinary teamwork and analgesia management. All patients were reviewed by physiotherapists but a significant proportion were not prescribed appropriate analgesia. The use of regional anaesthetic techniques increased. However, these skills still lie with a relatively restricted group, resulting in long waiting times.

Low back pain,is one of the more spread disease in the world,specially in elderly people with comorbidity.The aim of this article is to show the effectiveness of acupuncture as an adjuvant to the classic epidural infiltration.Because elderly patients have coronary disease,hypertension,diabetis and dislypidemia,it was better to associate acupuncture and not NSAID or analgesic or antidepressant 0r neuropathic drugs that all have some abuse to the elderly ill patient

We took a 20 elder patients aged more 65 years old half of them female with at least two diseases of:coronary artery disease,hypertension,diabetis second type,dyslipidemia.After having the result of the IRM,the patients received an epidural infiltration with depomedrol(methylprednisolone) 1mg/kg between the levels L2-L3,or L3-L4, or L4-L5, or L5-S1.Also they received twice in the week an acupuncture session with moxibustion with or without neurostimulation for one month for low back pain in the acupoints:EX-B2,BL-23,2425,26,54,57,13,GB-30,32,34,39,GI-4.Those whose hacing aspirine,they stopped 5 days before the process

16 of the patients after one month had a relief of 80% of their low back pain and they were pleased with the outcome,the other 4 patients had a second epidural infiltration with methylprednisolone and their pain was relieved also about 80%

Acupuncture as an adjuvant in the therapy of low back pain by epidural infiltration in elderly ill patients with comorbidity could help in relieving pain instead traditional drugs that might abuse these patients

Intrathecal opioids confer superior postoperative analgesia to systemic opioids as they deliver analgesia directly to their site of action while curtailing the undesired side effects. The present study aimed to determine the optimal dose of intrathecal morphine and hydromorphone in patients undergoing minimally invasive colorectal surgery.

The study was a double-blinded prospective trial and was approved by the ethics committee (IRB 20-009205). Patient were randomized into intrathecal morphine or hydromorphone group and dosing was determined by a sequential up-down method using a biased coin design. The primary outcome was ED90 of both agents to achieve numeric rating pain scores (NRS) ≤4 with postoperative opioid requirements ≤15 oral morphine equivalent at 12 hours.

Eighty patients completed the study. The ED90 for intrathecal morphine and hydromorphone could not be determined for the examined dose ranges (25-400 mcg and 10-200 mcg, respectively). The ED50 for morphine was 100 mcg (95% CI was below the lowest dose) and for hydromorphone was 75 mcg (95% CI 50–200 mcg). Morphine median (interquartile range, IQR) NRS scores was 3.0 (1.5-4.5) at 12 hours and 3.0 (2.0-4.0) at 24 hours, whereas hydromorphone median (IQR) NRS were 3.0 (1.5-5.0) at 12 hours and 3.0 (2.0-5.0) at 24 hours.

The study could not establish an ED90 for IT dosing for minimally invasive colorectal surgical patients. However, we did determine the ED50 for both agents. Patients reported to be very satisfied in their postoperative analgesic regimen in all dosing categories and no serious adverse events were observed throughout the study duration.