A bibliometric approach using network analytical methods was applied to explore the research trends on anesthesia for hip fractures.

Publications related to anesthesia for hip fractures from 2013 to 2023 were retrieved from the Web of Science. The keywords were “Anesthesia and hip fracture”, “Anesthesia in hip fracture”, “Fascia Iliaca Block”, Fascia Iliaca Compartment Block”, and “Pericapsular Nerve Group Block”. The extracted records were analyzed in terms of publication year, research area, journal title, country, organization, authors, and keywords. The research trends on anesthesia for hip fractures were visualized using the VOSviewer program.

Analyses of 1022 articles revealed that total number of publications has continually increased over the last decade (Figure 1). The country producing the most articles was the US, followed by China, Turkey, England, Canada, and India (Table 1). It was seen that most articles were published in Medicine, Cureus Journal of Medical Science, Journal of Orthopaedıc Trauma, Regional Anesthesia and Pain Medicine (Table 1). A network analysis based on the cooccurrence of keywords revealed the following two major study designs: clinical study and research methodology. It was determined that there was an increase in the number of studies on anesthesia in hip fractures (Figure 2). The most used keywords were hip fracture, pain, anesthesia, analgesia, nerve bloc, fascia iliaca compartment bloc, pericapsular nerve group bloc, fascia iliaca bloc, and femoral nerve bloc.

This study examined the research trends on anesthesia in hip fractures using bibliometric methods. Findings provide useful guidelines for researchers in searching for relevant topics.

With the population ageing, the incidence of fractures and thus orthopaedic surgeries among the elderly is increasing. These patients are often frail, making their perioperative management challenging, as this case aims to illustrate.

An 81-year-old female patient, ASA IV, with history of severe left ventricular dysfunction �LVD� (ejection fraction of 29%) was admitted with a subcapital femur fracture, proposed for surgery. Upon arrival to the operating room, a sinus bradycardia �(52bpm) and a mean arterial pressure �MAP� of 100mmHg were noted. An arterial line was placed and an ultrasound-guided suprainguinal fascia iliaca nerve block was performed (Ropivacaine 0,375%, 75mg) followed by a spinal block (Bupivacaine 0,5%, 7,5mg and Sufentanil 2,5μg). Five minutes later, MAP dropped �(65mmHg) and a bolus of Phenylephrine 100μg was administered, successfully. To maintain adequate MAP, a Phenylephrine perfusion was initiated. For sedation, a Dexmedetomidine perfusion was started. Intra and postoperative periods were uneventful.

In this patient, under beta-blocker therapy and with severe LVD, maintaining an adequate MAP and heart rate is essential. A spinal block complemented by an analgesic nerve block is an effective technique. However, due to reduced peripheral vascular resistance and absence of compensatory mechanisms, a Phenylephrine perfusion was required. Sedation was performed considering intraoperative environment and patient request.

In frail patients, the use of reduced local anaesthetic doses and the combination of regional techniques decrease anaesthetic risks, improving surgical outcomes. These strategies enhance the safety of anaesthesia, emphasising the importance of customised approaches to ensure successful outcomes in the elderly.

A 68-year-old male, ASA III, underwent a total knee arthroplasty under combined spinal-epidural anaesthesia. In the seated position, a Tuohy needle was inserted at the L3-L4 spinal segment. Using a saline solution, the epidural space was identified through the loss of resistance technique. The epidural catheter was placed 10cm from the skin. The procedure had no other complications.

On the third postoperative day, two hours after the removal of the epidural catheter, the patient reported an incapacitating frontal headache, facial paresthesias, a “distant voice” feeling, and nausea/vomiting. After Neurology’s and Neurosurgery’s evaluations, a head CT was performed, revealing intraventricular aeroceles at the frontal and temporal horns of the lateral ventricles. A pneumocephalus following the epidural technique was assumed to be the cause. Rest, oral hydration, multimodal analgesia (acetaminophen, ketorolac, metamizole, tramadol SOS), and a short corticotherapy’s cycle were applied. Two days later, upon neurological and neuroimaging improvement, the patient was discharged.

Pneumocephalus is a self-limited condition characterized by the presence of air in the epidural, subdural, or subarachnoid spaces[1]. Whichever the situation, the air pockets compress encephalic structures, increasing intracranial pressure and leading to multiple neurological manifestations (such as headache and focal neurological deficits), depending on the volume of air and its location[1,2]. The head CT is the gold standard for diagnosis. Treatment is primarily symptomatic (rest, a 30º head position, and analgesics), being high-flow oxygen, hyperbaric oxygen therapy, and surgery secondary options[1,3].

This case underscores the importance of awareness in the prompt identification of neuraxial complications, despite their rarity.

In the case we presented,the VATS operation, which was a multiple interruption intubation attempt and had difficult airways, using epidural anesthesia. We provided the necessary sedation during the surgery with dexmedetomidine infusion.

A 53years old female patient;body weight 80kg,height 160cm, ASA2, presented with Augmentin allergy, hypothyroidism, pulmonary nodules in the mediastinal+parenchymal tissues.The patient had a history of previous surgeries, multiple cesarean and a failed attempt at ventilation during VATS surgery one month ago, necessitating extubation due to suspected bronchospasm.Elective left VATS+Bx operation was planned, opting for awakeVATS due to previous difficulty with intubation.AwakeVATS operation under epidural anesthesia with dexmedetomidine iv infusion was planned. The patient received 1mg dormicum and 50mcg fentanyl for sedation, and was placed in the lateral decubitus position. An epidural catheter was inserted at the T5-T6 level. For induction 8cc 0.5% bupivacaine+2cc fentanyl+1cc NAC+4cc saline were administered through the catheter.In order to ensure patient compliance throughout the operation,0.3 mg/kg dexmedetomidine infusion was started.Maintenance included a mixture of 0.125% bupivacaine+2cc fentanyl at a rate of 7ml/kg/hr. N.Vagus was performed by surgeons to suppress the cough reflex.

During the operation, the patient was oriented to hold her breath while parenchymal biopsy was performed, ensuring reliable saturation levels. The procedure lasted for 4 hours and was successfully concluded.Transferred to the cardiothoracic ICU postoperatively.

Recent studies have reported that non-intubated VATS operations can be feasible and safe for patients with compromised airways. Patient selection, surgical planning, and preparation are critical stages that require meticulous collaboration between experienced surgical and anesthesia teams

Myotonic dystrophy type-1 is a multisystemic disease with autosomal dominant inheritance which is associated with muscle weakness, periodic myotonia and cardiac conduction abnormalities. These patients are at increased risk of perioperative respiratory complications due to aspiration of gastric content and post-operative worsening of underlying restrictive lung disease. Although there is no association with malignant hyperthermia, anaesthesiologists should avoid myotonic crisis triggers such as hypothermia, shivering, pain and succinylcholine. We aim to discuss anaesthetic options for a unique case of a myotonic dystrophy type-1 patient proposed for external fixation of lower limb bilateral trauma fractures.

15-year-old male, with a background of myotonic dystrophy type-1, victim of a high impact pedestrian-car collision resulting in multiple injuries (right lung contusion, bilateral femoral shaft fractures and bilateral pubic rami fractures), to be submitted to external fixation of lower limb fractures. The patient was carefully positioned with the cooperation of orthopaedists in a left lateral decubitus position, and a combined spinal and epidural anaesthetic technique was performed. The surgery was uneventful and postoperative pain management was guaranteed with continuous epidural infusion of ropivacaine

The complexity of this case is related to the risks associated with myotonic dystrophy type-1 combined with the injuries caused by trauma. To minimize postoperative respiratory complications, the priority was to minimize opioids, induction agents and avoid neuromuscular blockers to maintain spontaneous ventilation. The bilaterality of fractures made mobilization more complex, but ultimately, and after discussion with the orthopaedic team, a left lateral decubitus was deemed safe to perform a neuraxial technique

Glossopharyngeal neuralgia is a rare cranial neuralgia that presents as recurring episodes of shooting sharp pain in the jaw, throat, tongue, and ear. This case report demonstrates a rare treatment of glossopharyngeal neuralgia with peripheral nerve block under ultrasound guidance.

A 69-year-old woman presented with unilateral, transient, piercing pain in the ear, the base of the tongue, tonsillar fossa, posterior pharynx, and submandibular region. It was triggered by chewing, swallowing, talking, yawning, or coughing. During the physical examination, the posterior wall of the ear canal was found to be painful when touched with a Q-tip. Head and neck MRI was unremarkable. She had previously failed to respond to pharmacological treatment. A diagnosis of glossopharyngeal neuralgia was considered. She underwent an ultrasound-guided anesthetic block of the glossopharyngeal nerve, 0.5% lidocaine and 40 mg methylprednisolone were slowly injected under real-time ultrasound guidance.

The patient had analgesic effects within 5 minutes of the injection. Following the treatment, the patient experienced just three moderate and short-lived episodes of pain over 24 hours. Subsequently, the patient returned to their baseline without any discomfort. She has not had another flair for three months since the block.

Currently, primary glossopharyngeal neuralgia is challenging to treat. Treatment includes carbamazepine, gabapentin, baclofen, or neurosurgical procedures if medication fails. We report the ultrasound-guided glossopharyngeal nerve block as a successful treatment for glossopharyngeal neuralgia. Given the limited efficacy of existing treatments, we urge neurologists and pain physicians to consider the implementation of this intervention as a viable treatment alternative.

We present a case of a 57-year-old male with a femoral neck fracture staged for a total hip arthroplasty. Due to a Mustard operation for a transposition of the great vessels in his childhood, the patient is now heart insufficient NYHA IV with regular Levosimedanin infusions and waiting for a heart transplant. Furthermore, he has a situs inversus and is pacemaker dependent for sick sinus syndrome.

Due to his medical condition, the anesthetic management of this patient required thoughtful planning and interdisciplinary consensus. Options such as spinal catheter or general anesthesia were discussed but rejected due to rescue back-up with ECMO / heart-lung machine and general anesthesia was considered too riskful. The surgical approach consisted in a total hip arthroplasty, regarding the patient´s condition uncemented, though. The anesthetic approach included preoperative optimization with Levosimedanin, preparation and standby for perioperative ECMO, spinal anesthesia and a femoral nerve block.

The operation went uneventfully, and the patient recovered well from the operation.

Our case report shows that it is possible to provide good anesthetic management even in challenging patients by having a clear perioperative planning and an open dialogue with our orthopedic colleagues.

Sheehan syndrome (SS) is a form of hypopituitarism caused by pituitary gland infarction after severe postpartum hemorrhage (PPH), leading to variable degrees of pituitary hormone deficiency. Main anaesthetic concerns include electrolyte imbalance, hypocortisolism, hypothyroidism, hypotension, hypothermia and reduced drug metabolism. Regional anesthesia techniques are usually beneficial in these patients in order to reduce hormonal stress response.

An 80-year-old female patient, ASA III, was proposed for reduction and osteosynthesis of a pelvic fracture. The patient had a diagnosis of SS based on past history of severe PPH with subsequent lactation failure and an empty sella turcica, associated with adrenal insufficiency, hypothyroidism and hyponatremia. Other known diagnosis included dyslipidemia. Due to ventral decubitus positioning, duration and extent of surgery, general anaesthesia is usually indicated in major pelvic surgery and because a posterior surgical approach was elected, use of an epidural catheter wasn´t recommended. We opted for total intravenous anesthesia associated with a subarachnoid block to reduce metabolic stress response to surgery and minimize intravenous opioid use.

Perioperative management included early admission for preoperative hyponatremia correction with hypertonic saline, glucocorticoid supplementation with intraoperative hydrocortisone 100mg intravenous bolus followed by 50mg every 8h postoperative. Before anaesthesia induction a subarachnoid block was performed in the L4-L5 interspace with 2ml of 0,25% levobupivacaine and 100mcg morphine. The procedure and recovery were successful and uneventful.

Adequate preoperative optimization is key in SS patients and the anaesthetic approach should be tailored to the patients’ needs and surgical requirements, profiting from the synergistic interaction between general and regional anesthesia.

A 26-year-old ASA 2 primiparous lady experienced motor and sensory block for more than 72 hours following uncomplicated spinal anaesthetic injection for elective Caesarean delivery. She had a BMI of 29.7 and multi-level disc herniation with episodic sciatica and previous steroid epidural injections.

Spinal anaesthetic was performed by an experienced operator without any immediate complications.

At 7 hours following the spinal injection, she continued to experience complete motor block of lower limbs and reduced sensation up to her hips. At this point she mentioned similar prolongation of block with epidural injections for pain on two previous occasions. MRI was performed at 25 hours due to unavailability overnight. The report ruled out an epidural haematoma. Neurology referral recommended conservative management. She started mobilising at 75 hours and was discharged home. On follow up she was asymptomatic.

Patient factors, such as low CSF volume [1], peak diastolic CSF velocity [2], and genetic predispositions [3] have all been linked to excessive block duration and may be unknown at the time of the procedure. In patients with pre-existing spinal stenosis, epidural injection may precipitate radiculopathy due to changes in local blood circulation [4], and patients suffering from demyelinating diseases may require lower doses of local anaesthetic, due to increased sensitivity of demyelinated neurons to the drug [5,6]. Understanding of causation is vital to establish whether procedures could be safely repeated in the future.

This presentation delineates the case of a 68-year-old female diagnosed with a substantial chondrosarcoma (8x12cm) involving both the left sacroiliac joint and L4-L5 left laminae. Surgical intervention entailed en bloc resection encompassing the left sacroiliac joint and L4-L5 hemilaminectomy, accompanied by osseal reconstruction and L3-L5 bilateral arthrodesis to achieve articular stabilization. General anesthesia was administered with the patient in the prone position along with lumbar epidural catheterization at L1-L2. However, due to the extensive surgical incision, removal of the epidural catheter was necessitated. Prior to removal, 4mg of epidural morphine were administered. Subsequently, a new epidural catheter was inserted at the L1-L2 level under fluoroscopic guidance to ensure positioning above the arthrodesis site. Postoperatively, the patient was expeditiously extubated with gradual discontinuation of vasoactive agents, experiencing pain-free convalescence facilitated by a ropivacaine 0.2% epidural infusion (4 ml/h).

Bone sarcomas, characterized by their substantial size and local invasiveness, demand comprehensive expertise in locoregional anesthesia. However, the applicability of locoregional techniques may be constrained by the tumor's extent. Although typically utilized in Pain Clinics, fluoroscopy serves as a valuable modality for guiding epidural catheter insertion, ensuring heightened precision and safety. Particularly in scenarios where surgical maneuvers may impede catheter insertion, fluoroscopic guidance emerges as an indispensable adjunct to secure optimal positioning, particularly in patients positioned prone.

In challenging catheterization scenarios, particularly within instrumented spines, fluoroscopy-guided techniques offer a pragmatic approach to ensure the safe and efficacious placement of epidural catheters.

Complications of regional anesthesia (RA), anesthesiological challenge and problem.Post dural puncture headache (PDPH) is considered the most common, almost expected.Pulsating headache after RA initially occipital with shoulder and neck pain,diffuse character,nausea,vomitingis initially defined as PDPH.Is it always like that?

Patient,30 years old,scheduled for inguinal hernia surgery.Preoperative unremarkable.The operation was performed in conditions of RA (L3-L4 spinal block),passed without complications(hemodynamic-respiratory stable). Postoperatively without complaints.On the second day,a severe headache of occipital postural character developed with nausea and vomiting. Neurologist consulted.Findings unremarkable-diagnosis of PDPH.On the third day,an epileptic attack followed by confusion and disorientation.An MSCT-hyperdensity was performed with a postcontrast deficit of the posterior segment of the sagittal sinus.Neurological findings indicate severe left-sided weakness,maintenance of psychomotor slowness with alert consciousness and preserved verbal communication.Anticoagulant (Fraxiparin 0.9ml sc/12h)was prescribed.Partial thrombosis of the sagittal sinus confirmed by NMR venography.After discharge, along with anticoagulants,an antiepileptic was also introduced. After 6 months control NMR-finding is completely normal,without the previously described defect.The patient feels well,without subjective complaints and repeated epileptic attacks.

PDPH is part of spectrum of differential diagnoses,closely related but different therapeutic strategies-meningitis,encephalitis,tension,lactation and cluster headache,cerebral venous thrombosis (CVT),subdural hematoma and intracranial mass. CVT-venous thromboembolism 4-6 patients per million patients per year with non-specific symptomatology.CVT defines:increasing headache,standing up does not increase it, analgesic non-responder.PDPH should always be viewed as a possible cause of postural headache, not as a definitive diagnosis,especially in the younger population-pregnancy,obesity and after COVID-19.

Timely diagnosis of CVT and early introduction of anticoagulants is crucial along with antiedematous and antiepileptic therapy.

Frail patients with hip fracture recommended for immediate surgery often present difficult spinal anatomy, which requires special expertise in performing ultrasound-assisted neuraxial block.

The patient (male, 71years, 60kg, 165cm tall after vertebral collapse, previously 180cm) was able to walk independently aided by a walking stick; an accidental fall caused left proximal femur fracture which required total hip arthroplasty the day after admission. ASA III/IV, El-Ganzouri score 6 (Mallampati 2, thyromental distance <6cm, neck movement <80°, questionable history of difficult intubation); no cognitive impairment. Medical History: Ipertension, Parkinson’s and Dysphagia, Myasthenia Gravis with moderate restrictive respiratory failure, history of respiratory arrest and pacemaker implant, severe kyphosis, vertebral collapse (T6-T12), bedsores (heels, back, sacrum). Within 1 hour from hospitalization paracetamol (1g/8 hours iv) was administered for analgesia and bedsores were routinely treated. Anaesthesia according to internal guidelines: - Ultrasound guided Peng Block with ropivacaine 0.5% 20ml, dexamethasone 8mg iv; - Ultrasound-assisted neuraxial block while sitting upright L2-L3 (Whitacre needle 25G), ropivacaine 0,5% 15mg

No further complications: -Alimentation: semi-solid diet 4hours after surgery (dysphagia); -Analgesia: paracetamol (1g /8hours iv) for 5 days and ketorolac in rescue dose; -Rehabilitation: starting the 2nd day (patient able to walk), discharge on the 5th day, continuing rehabilitation at home. At 1 year check-up patient shows good condition, complete absence of bedsores and a full recovery.

Our clinical case shows how adapting evidenced based medicine and internal guidelines to the specific clinical setting, taking advantage of new technologies, is key for optimal patient management.

Central neuraxial blocks are a relatively safe procedure with the risk of major complications being relatively rare. Hence, it is usually the preferred anaesthesia technique for lower segment Caesarean section (LSCS) surgery. However major complications can include cardiovascular collapse, complete neuraxial block, vertebral canal haematoma, nerve injury and meningitis.

A 33 year-old Chinese lady presented for elective caesarian section at a gestational age of 39+3 weeks. She had no known drug allergies and no significant past medical history apart from a body mass index of 36 kg/m2 (93kg, 161cm). Ultrasound-assisted spinal anaesthesia was performed at the L4/5 interspace with a 27-gauge pencil point spinal needle. 2.4ml of 0.5% heavy bupivacaine, 15mcg of fentanyl and 0.1mg of morphine (in a total of 2.8ml) was administered. A block height of T4 was established within 10 minutes, surgery was commenced and a healthy baby was delivered uneventfully.

Twelve minutes after delivery, the patient started to desaturate and subsequently became unresponsive. Her airway was secured with endotracheal intubation and her ventilation and haemodynamics remained stable. Investigations including a CT brain were unremarkable and she subsequently regained consciousness and made a full recovery. We postulate that her presentation was possibly due to a subdural block given the delayed and atypical presentation.

While subdural blocks are a rare complication of central neuraxial blocks, it is important to consider this differential in patients presenting with atypical symptoms following a central neuraxial block.

Prilocaine, an amide-type local anesthetic, is known for its fast onset and intermediate duration of action. This retrospective analysis compares the duration of spinal anesthesia with prilocaine and ropivacaine in patients undergoing transurethral removal of bladder tumors (TURBT).

Thirty patients scheduled for TURBT were divided into two groups: one receiving ropivacaine 7,5% (n=15) and the other prilocaine 5% (n=15). The primary hypothesis was that patients receiving prilocaine would have shorter duration of sensory and motor blockade and thus would bypass post-anesthesia care unit (PACU). Secondary outcomes included recovery, hemodynamic and immediate postoperative complications.

Both groups were similar in terms of demographic characteristics (Age, BMI, Gender), ASA classification and duration of surgery (GroupPrilocaine=36.7±13.8, GroupRopivacaine=43.8±24.4, p=0.337). The duration of sensory and motor blockade was found to be statistically significant less in patients receiving prilocaine, compared to the patients receiving ropivacaine (GroupPrilocaine= 38.3±17.8, GroupRopivacaine=61.3±33.1, p=0.025). Additionally, patients in the prilocaine group had shorter PACU duration and less mean arterial pressure drop after the performance of spinal anesthesia, when compared to the ropivacaine group patients (GroupPrilocaine= 14.7±4.11, GroupRopivacaine=22.9±6.70, p<0.001). No complications were reported.

Prilocaine, compared to ropivacaine, contributes to a shorter duration of motor and sensory blockade, leading to a faster recovery in patients undergoing transurethral bladder tumor removal, while offering hemodynamic stability. This study suggests that prilocaine administered in spinal anesthesia for patients undergoing TURBT, may offer advantages over ropivacaine, potentially improving perioperative management and patient outcomes.

Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS), a rare congenital condition (1-9/100,000 women), is characterized by uterine and vaginal agenesis with normal female karyotype and intact ovaries. Management through Vecchietti surgery consists of an acrylic "olive" inserted into the vaginal dimple connected to an abdominal traction mechanism for daily vaginal cavity formation (figure 1).

Description of the perioperative management for a modified Vecchietti surgery. Informed consent for case publication was obtained.

A 17-year-old female, ASA II underwent laparoscopic modified Vecchietti technique with suprapubic cystotomy for neo-vagina creation. The patient had well-controlled asthma and anxiety. Before induction, an epidural catheter was placed in the L3-L4 space. The procedure occurred under ASA standard monitorization and balanced general anesthesia with orotracheal tube, for 2 hours, without complications. Post-operatively, pain control was managed through a multimodal approach, including acetaminophen, cetorolac, and epidural analgesia with 1.5mg of morphine every 12 hours, supplemented by 8ml of 0.2% ropivacaine every 6 hours as needed. Epidural analgesia bolus was administered before daily traction. After 8 days, the desired vaginal length was achieved, with device removal and vaginal mold insertion. The epidural catheter was also removed maintaining oral analgesia. The pain remained well-controlled and the patient was discharged on postoperative day 13.

The literature on the anesthetic approach to neovagina construction surgery is still scarce. Preoperative anesthetic planning and standardization of anesthetic care are crucial for these patients. In this case, epidural anesthesia played an essential role in postoperative pain control, particularly during daily mechanical traction.

Total spinal block, characterized by extensive sensory and motor blockade beyond the intended spinal level, is an uncommon but a serious complication of neuraxial anesthesia. The mechanisms underlying this phenomenon, particularly with combined spinal-epidural techniques, remain unknown.

We present the case of a 32-year-old woman, admitted for labor induction at 41 weeks gestation. Combined spinal-epidural anesthesia was performed for labor analgesia. An unintended dural puncture with the Tuohy needle was identified, with the epidural catheter inserted at a lower level. Using a combined technique, an intrathecal dose of sufentanil and ropivacaine was administered, followed by the uneventful administration of 3mL lidocaine 2% through the epidural catheter. Epidural analgesia was maintained with protocol of ropivacaine/sufentanil bolus, administered by nurses upon patient request.

Nine hours later, cesarean was performed due to fetal hypoxia. Lidocaine 2%, ropivacaine 0.75%, and sufentanil were administered via the epidural catheter. Paresthesias were reported, followed by respiratory arrest, with no signs of hemodynamic instability. Emergency tracheal intubation and cesarean delivery were performed, with no consequences for the newborn. The patient was transferred to the ICU, where motor block regression occurred approximately 5 hours later with successful extubation.

The occurrence of total spinal block in this case prompts hypotheses such as epidural catheter migration into the intradural space or local anesthetic migration through the dural puncture site. This rare occurrence emphasizes the importance of preventive protocols during dural puncture. Further research is needed to understand the mechanisms and risk factors for total spinal block in combined spinal-epidural anesthesia.

Patients with cardiovascular and respiratory comorbidities present a challenge for anesthesiologists. In this context and in the era of an ever-increasing opioid epidemic, regional anesthesia and analgesia modalities in combination with opioid-sparing conscious sedation techniques with the aim to avoid general anesthesia while at the same time maintaining a high safety profile may be the best multimodal anesthetic approach.

We present a case of a patient scheduled for radical abdominal hysterectomy. Due to many comorbidities, the presence of a month-old persistent cough and the fact that the surgery had to be performed under an extended midline vertical incision, we decided on a combination of segmental epidural anesthesia and conscious sedation. Thoracic epidural was performed, while, before surgical incision, dexmedetomidine, ketamine and lidocaine were administered as an intravenous bolus, followed by a continuous infusion of a mixture of dexmedetomidine, ketamine and lidocaine throughout surgery.

During the operation, the patient was relaxed, responsive to verbal commands, maintained spontaneous ventilation and was completely pain-free even during peritoneal traction and enteral manipulation. The surgical procedure was completed uneventfully and epidural analgesia via a PCEA pump was provided postoperatively. The postoperative course was unremarkable and the patient was discharged within a few days.

In this case, we supplemented the segmental epidural technique with sedation via a mixture of dexmedetomidine, ketamine and lidocaine, used until now only in patients undergoing surgery under general anesthesia in opioid-sparing protocols. This report highlights the importance of multimodal approaches in the case of demanding procedures in patients with comorbidities.

An elderly female patient had an epidural catheter insitu for a second revised hip replacement. On third postoperative day, she developed symptoms suggestive of epidural haematoma. With surgical clips in place at the operated site MRI scan of the spine was delayed due to concerns of surgical clips displacement and heating under the MR scanner. MR scan was performed later that evening after contacting the surgical clip company for MR safety.

Literature search was initiated after deciding the search words and performed in Pubmed and EMBASE Results were de-duplicated using RefWorks.

Most surgical skin clips in current use are either non-ferromagnetic or minimally ferromagnetic, making them safe for use with MRI scans, provided the scanner's strength is less than 3 TESLA. The Medicines and Healthcare products Regulatory Agency (MHRA) has established guidelines recommending that hospitals ensure proper identification, documentation, imaging, and aftercare for patients with implantable medical devices who require MRI scanning. These guidelines are updated annually. No case reports over the past 15 years have been identified that indicate surgical clips cause tissue damage or migration when subjected to an MRI scanner. At least five case studies have tested the effects of different skin clips under MRI scanners, with three studies using 1.5 TESLA scanners and two using 3 TESLA scanners. All results indicated that the clips were safe under these conditions.

Established hospital guidelines should be in place for MRI Scan in patients with surgical clips. This will minimise delay which may have negative impact on patient outcomes.

Needle breakage or deformation during spinal anesthesia occurs infrequently and represents a serious complication with potentially adverse effects.Several case reports were published to deal with this rare complication and address the topic while looking at the incidence, risk factors, and ways to prevent broken or deformated needles while receiving spinal anesthesia. There are a number of risk factors that are associated with potential deformation or fracture of spinal needles during subarachnoid anaesthesia.

We report a case of a deformated spinal needle into a zingzang shape, while perfoming a subarachroid anesthesia in an obese woman(BMI= 68) indicated for an emergent trimalleoral fracture.

Multiple puncture attempts due to difficult identification of lumbar spine, the lack of experience of the resident, the low-quality of the equipment, the lack of expiriense in using the urltasound and the extra high BMI of the patient contributed to this complication. The recognition of predictive factors for difficult neuraxial anesthesia, the use of ultrasound in obese patients, and a properly executed technique may have allowed avoiding this complication.

Spinal needles are designed and manufactured to be strong and durable. However, factors such as improper use, manufacturing defects, or accidental trauma can potentially lead to needle breakage. The use of proper techniques, the use of ultrasound, the use of high-quality equipment, and adherence to safety guidelines significantly reduce the risk of such incidents.

Epidural empyema is a rare complication following epidural catheter (EPC) placement. It’s a life-threatening situation if not quickly diagnosed and treated with risk of permanent neurological damage.

An EPC was placed on a 62YO ASAIV male with acute peripheral obstructive artery disease undergoing lower limb angioplasty.

Nineteen days later he presents with fever and increased inflammatory parameters. Neurological examination was unremarkable. EPC insertion site didn’t show inflammation or infection signs of. Pseudomonas Aeruginosa was isolated in urine and blood cultures and empirical antibiotic therapy was started. On 20th day, purulent exudate at the EPC insertion site appeared and the EPC was removed. The patient remained without neurologic deficits or meningeal signs. P.aeroginosa was isolated from EPC tip culture and antibiotic therapy was targeted. Two days after, loss of sensitivity at L1-L4 territories and loss of anal sphincter continence appeared. No motor deficits. An urgent MRI revealed an empyema from S3-T9 without significant spinal cord compression or distress signs. Neurosurgery recommended Conservative management was recommended by neurosurgery. One week after targeted antibiotic therapy, deficits reversed to patient's baseline. Three months follow-up revealed no sensory or motor sequelae.

This case represents a CNS infection after EPC technique resulting from a neuraxial anesthetic technique with a favorable evolution under conservative treatment. The diagnosis requires a high degree of suspicion and is not excluded by absence of neurological deficits. Inflammatory markers are a warning sign but only MRI could confirm the diagnosis. Timely diagnosis and multidisciplinary approach are essential and mandatory.

After radical mastectomy, many patients undergo breast reconstruction. Autologous flap reconstruction avoids many issues despite being longer and complex. The DIEP (deep-inferior-epigastric-perforator) flap is the most common procedure, involving the transfer of skin and subcutaneous fat from the abdomen to the chest. The procedure takes many hours and requires optimal intraoperative analgesia and hemodynamic stability. Flap perfusion may benefit from spontaneous breathing. We considered spinal anesthesia with fascial-plane-blocks an alternative to general anesthesia to improve outcomes and recovery.

A 59-year-old woman (history of breast cancer, mastectomy, failed breast implant reconstruction) scheduled for reconstruction with DIEP flap. After signing informed consent and premedication with midazolam and atropine, spinal anesthesia and bilateral inter-transverse-process block (ITP) were performed. For spinal anesthesia at T10 with 27G needle, we administered 5 ml of ropivacaine 2mg/ml, fentanyl 20 mcg, and dexmedetomidine 5 mcg. For ITP block at T7: 30 ml of ropivacaine 0.2% and dexamethasone 4 mg each side

The 7-hour surgery was conducted under moderate sedation with propofol. No bradycardia occurred; moderate hypotension was corrected with ephedrine. Mean arterial pressure remained stable. Oxygenation was maintained with O2 via nasal cannula. Additional fentanyl was administered at the end of surgery. The patient awakened pain-free and was monitored for flap perfusion and oxygenation for 24 hours; began early refeeding and mobilization without pain or nausea and was discharged home earlier.

High-volume/high-level spinals with adjuvants can be valid alternatives to epidural and general anesthesia for long-duration procedures like DIEP flap breast reconstruction. Trials are needed to evaluate advantages.

Continuous spinal anaesthesia (CSA) is a well-established technique, successfully used in many surgical procedures in high-risk patients, allowing careful titration of local anaesthetic drugs with ideal blockage level and minimizing hemodynamic effects. We report using CSA in a patient undergoing left inguinal hernia correction.

A 61-year-old patient, ASA IV, with arterial hypertension, a history of aortic valve replacement surgery four months ago, and severely reduced ejection fraction (EF 20%), was scheduled for elective inguinal hernia correction. Informed consent was obtained. Standard ASA monitoring and invasive arterial blood pressure were instituted. The patient was placed in right lateral decubitus. CSA was performed with an 18G Tuohy needle through a median approach at L3-L4 interspace. Once free flow of cerebrospinal fluid was obtained, an epidural catheter was inserted and the patient was placed in supine. 3.75mg of isobaric bupivacaine was administered, followed by a 1,3mL saline bolus. Surgery began when a sensory block to pinprick at the T10 dermatome was established. The patient experienced discomfort and the block was augmented with 1,8 mg of isobaric bupivacaine. Multimodal analgesia and postoperative nausea and vomiting prophylaxis were completed.

The surgery lasted 40 minutes. The patient remained hemodynamically stable throughout, with no need for vasoactive drugs. At the end of surgery, the catheter was removed and the patient was transferred to post anaesthesia care unit. There were no reports of post-dural puncture headache.

CSA guarantees minimal side-effects and clinical efficacy in individualized patients who are not fitting candidates for general, single-shot spinal or epidural anaesthesia.

General and neuraxial anaesthesia may induce significant hemodynamic instability in frail, high-risk patients. Continuous subarachnoid block (CSB) allows precise titration of local anaesthetics with ideal blockage level and minimal hemodynamic effects. We report using a CBS for an urgent hip fracture repair.

An 89-year-old patient, ASA IV, with severe aortic stenosis, NYHA III heart failure, asthma, and chronic kidney disease presented for urgent hip fracture repair. An informed consent was signed. ASA monitoring was instituted. The patient was placed in right lateral decubitus, and CSB was performed through a median approach using an 18G Tuohy needle at L3-L4 interspace. Once free flow of cerebrospinal fluid was identified, an epidural catheter was introduced, and the patient was placed supine. 3,5 mg of isobaric bupivacaine 0.5% was administered, followed by a 1,3mL saline bolus. When a sensory block was established at the T8 level, the patient was positioned on a traction table and the surgery began. Multimodal analgesia was completed with ketorolac and paracetamol. Ondansetron was administered as nausea and vomiting prophylaxis.

The surgery lasted 45 minutes. Despite administration of a very small dose of anaesthetic, the patient needed 18mg of ephedrine to maintain hemodynamic stability. There was no need for further administration of anaesthetic. At the end of surgery, the catheter was withdrawn; the patient was transferred to post anaesthesia care unit. There were no reports of post-dural puncture headache.

Continuous spinal block is very effective for delivering titrated neuraxial anaesthesia with lower doses of local anaesthetic and minimal hemodynamic repercussions.

Regional anesthesia techniques are important alternatives in patients with pre-existing cardiac disease. By reducing hemodynamic fluctuations and surgical stress response they are less impairing for cardiac function.

A 75-year-old, ASA IV female patient proposed for gamma nail fixation of intertrochanteric fracture with medical history relevant for left ventricular pseudoaneurysm secondary to recent myocardial infarction treated with primary angioplasty and acute peripheral artery disease managed with intra-arterial thrombolysis. Due to the patient’s comorbidities, it was decided to perform a low-dose single-shot spinal anesthesia combined with infrainguinal fascia iliaca block. Informed consent was obtained.

Standard monitoring was started, an arterial line placed and oxygen delivered by nasal cannula. A ultrasound guided infrainguinal fascia iliaca block was performed using 30ml of 0,375% ropivacaine. The patient was then moved to the operating table and placed in left decubitus for spinal anesthesia. After aseptic preparation, a 27G spinal needle was inserted at L3-L4 level and 6 mg of isobaric bupivacaine and 2 micrograms of sufentanil were administered. The level of sensory block was observed in T12 and motor blockade was complete on both lower limbs. The surgical procedure lasted for 40 minutes with hemodynamic stability throughout. The patient was transferred to the ICU for postoperative monitoring, where she stayed for 24 hours hemodynamically stable and with good pain control.

Elderly and fragile patients are an anesthetic challenge. Regional anesthesia techniques are a great option due to their lower cardiovascular impact, effective postoperative analgesia and no consequence on cognitive function.

Video-Assisted Thoracic Surgery (VATS), a minimally invasive surgery usually performed under general anesthesia. Like in Laparoscopic and breast surgeries, Thoracic segmental spinal anesthesia may be a viable option as a regional anesthesia approach in VATs. The use of this technique as an alternative to general anesthesia is much simpler compared to other regional anesthesia techniques.

A 51-year old ASA II male was schedule for VATS biopsy and deloculation. The patient was informed of the anesthesia technique and provided informed consent. Thoracic segmental spinal anesthesia was done by slowly injecting a mixture of Bupivacaine 0.5% Isobaric 5mg, Fentanyl 20 mcg, Ketamine 10mg, and Dexmedetomidine 5 mcg intrathecally at the level of T6-7 interspace using a gauge 25 spinal needle via paramedian approach. No recorded paresthesia or any problems during the puncture or injection of anesthetic were encountered.

After confirming the desired block height of T1-9 surgery was started. Lidocaine bolus followed by a low-dose infusion was started to reduce the coughing reflex or reflexive bronchoconstriction during lung manipulation. The procedure commenced without any complications. Patient remained comfortable, easily arousable, and responsive during the whole operation. The surgery lasted for 1 hour and 45 minutes, with no complaints of pain and discomfort from the patient.

Awake VATS presents a particular challenge to the anesthesiologist and requires extra vigilance. Current preliminary data support the feasibility and safety of awake VATs under regional anesthesia, especially by thoracic segmental spinal. Nevertheless, large scale studies are needed before the overall risk and benefits can be concluded.

This case aims to highlight the benefit of early epidural catheter placement in refractory pain in acute pancreatitis.

Case report.

A 60-year-old male patient presented to the ER with intense abdominal pain. Past medical history included chronic alcohol abuse, hypertension, chronic pancreatitis, smoking habits and peripheric polyneuropathy. Complementary exams revealed an elevation in amylase and lipase hence a diagnosis of acute on chronic pancreatitis was assumed. During his stay in the ER, the patient developed a hypotensive status with poor peripheric perfusion requiring the initiation of vasopressors. A CT scan showed signs of a necrotizing pancreatitis. Despite optimized multimodal IV analgesia, the patient remained relentless due to excruciating pain so a decision to place a high lumbar (L1-L2) epidural catheter was made. Administration of 10ug sufentanil and 8mg of ropivacaine and subsequent boluses of 0,1% ropivacaine allowed for optimal pain control without increasing vasopressor needs. The patient was admitted to the ICU and regardless of adequate resuscitation, the patient deteriorated due to worsening emphysematous pancreatitis and ischemic colitis, culminating in refractory shock.

Pain secondary to acute pancreatitis can be refractory to multimodal strategies and practitioners should consider early epidural placement. Segmental sympathetic block can improve splanchnic perfusion and decrease the incidence of complications, namely ARDS and AKI. Nonetheless, the literature is sparse on timing, level of catheter placement as well as in the choice of drugs for optimal pain management. The incidence of local and neurological complications is extremely low, making it a effective and safe analgesia alternative.

The prevalence of Lumbar spinal stenosis ranges from 11 to 39% (Jensen R.K, et al, 2020). A recent paper from Denmark reveals that 46% of those with Lumbar spinal stenosis underwent decompression surgery (Jensen R.K, et al, 2023). Patients presenting with a history of spine surgery is not infrequent these days.

We present a 76-year-old lady posted for a Total Knee Arthroplasty who had lumbar decompression with fusion from L2 to L5. She had her hips replaced under spinal anaesthesia prior to the spine-surgery. She was keen to have this surgery under a spinal anaesthetic. Mr J A Taylor, a Urologist, first described spinal anaesthesia at L5-S1 for procedures on the prostate and bladder (Taylor, 1940). The spinal tap was performed with the patient in prone position using a paramedian approach 1 cm inferomedial to the posterior superior iliac spine. As her fusion extended from L2 to L5, we opted for a modified Taylor’s approach with the patient in sitting position.

A pre-procedure ultrasound scan was performed to evaluate and identify the L5 – S1 space. The ligamentum flavum-dura mater complex was identified on the right paramedian sagittal oblique view and the entry point was marked. The spinal anaesthetic was performed successfully in a single attempt.

Challenging spinal anatomy does not mandate the use of a general anaesthetic. Previously described techniques like Taylor’s approach combined with the use of ultrasound can improve the success of neuraxial anaesthesia. This can improve patient outcome and satisfaction.

Morel-Lavallée lesion is a closed degloving injury associated with high energy trauma. The skin and subcutaneous tissue are forcibly separated from the underlying fascia, creating a potential space filled with hemolymphatic fluid. We present a case of a 42-year-old, ASA II, female patient, victim of incarceration after a motor vehicle collision with immediate bilateral above the knee amputation, thoracic and pelvic trauma.

On the 10th day after ICU admission an epidural catheter (EPC) was placed at L3-L4 level, by midline approach, using a loss of resistance to air technique with a 16G Tuohy needle and negative aspiration.

Following patient repositioning, it was noticed a pericatheter fluid leakage and 5 ml of saline were administered without an increase in drainage. It was decided to delay the start of the EPC infusion. Throughout the day, there was a continuous abundant drainage of liquid. A CT scan was performed to rule out cerebrospinal fluid-cutaneous fistula. Because the imaging test was unremarkable, Morel-Lavallée lesion was suspected and an MRI was ordered to confirm the diagnosis. The MRI did not show any collection of fluid, but since the scan was performed 3 days after the initial presentation it is possible that the lesion was already drained. The EPC infusion was started and the patient was extubated the next day without neurological deficits.

Morel-Lavallée lesion is frequently underdiagnosed. In this case, EPC technique was essential to rule out intrathecal placement and was also the treatment for this condition. No similar case reports were found in literature.

The development of neurological symptoms after regional anesthesia constitute primary anesthesia-related complication. However other, even life-threatening conditions, should not be overlooked.

Case report

A 73-year-old male, ASA 3, was scheduled for perianal fistula repair under spinal anesthesia. Medical history included heart failure, COPD, ischemic stroke without any neurological deficit, and chronic atrial fibrillation, treated with rivaroxaban 20mg qd, stopped four days before surgery without bridging. Previous general anesthesia was complicated with severe post-operative delirium. Clinical examination on the day of surgery revealed mitral systolic murmur and mild wheezing, METs <4. Ambulatory surgery was performed under spinal anesthesia and recovery was uneventful without signs of residual nerve block. Patient received rivaroxaban 6 hours post-surgery, against medical advice, and, within 2 hours, developed acute back and abdominal pain with paraplegia and was admitted to the ER. Neurological examination revealed complete motor and sensibility loss of the lower limbs. Lumbar-spinal MRI was performed, with no signs of epidural hematoma. Transient neurological symptoms were suspected. During the following 12 hours, mobility and sensibility of the legs presented mild fluctuation, related to the patient’s body posture. CT-angiogram revealed acute abdominal aortic obstruction. The patient underwent open aortic surgery and was transferred to the ICU, where he deceased the next day due to multiple organ dysfunction.

In any patient presenting with acute onset neurological symptoms after spinal anesthesia, and epidural hematoma has been ruled out, other causes should be examined, including vascular obstruction or aneurysm, even if considered unrelated to anesthesia. A multidisciplinary approach is necessary.

Cerebral venous thrombosis (CVT) is a rare complication of dural puncture and it is often related to the presence of predisposing factors, such as pregnancy and puerperium. Because the clinical symptoms of CVT can resemble those of a post-dural puncture headache (PDPH), the diagnosis may be delayed.

Case report.

A previously healthy 30-year-old woman Gravida 1 Para 0 presented in active labour at 40 weeks gestation, requesting epidural analgesia. An unintentional dural puncture occurred with an 18G epidural needle and a catheter was placed in the subarachnoid space for analgesia. The vaginal delivery occurred two hours later and it was uneventful. The following day, the patient complained of a frontal-occipital orthostatic headache that improved when positioned supine, with no other symptoms. Pain management with analgesic drug therapy was successful for the first two days, but thereafter she began to again complain of a headache, with the same positional component. An epidural blood patch was performed with relief of symptoms. She was observed by the neurology team which ruled out any neurological deficits but still ordered a brain CT. Imaging was consistent with CVT and the patient was started on enoxaparin. Thrombophilia workup was found to be negative. She remained asymptomatic and was discharged home 5 days later with transition of the anticoagulation therapy to dabigatran.

This case highlights the importance of considering CVT in the differential diagnosis of headache in the post-partum period. Despite its impact on quality of life, PDPH doesn't carry the life-threatening risk of CVT.

Intrathecal morphine is commonly used for postoperative analgesia, with recommended doses typically ranging from 0.1 to 0.3mg. Despite its efficacy, adverse effects such as respiratory depression, hypotension, pruritus, and urinary retention can occur, particularly with higher doses. This report aims to discuss the clinical management and outcomes of a patient who inadvertently received a supratherapeutic dose of 2mg of intrathecal morphine.

We present a clinical case involving a 72-year-old male, ASA II, scheduled for abdominoperineal resection, considered for a combined anaesthetic technique (neuraxial block and general anaesthesia). Multiple attempts at epidural blockade were unsuccessful, leading to perform a subarachnoid block with 0.2mg of morphine. However, a preparation error resulted in the administration of 2mg of intrathecal morphine.

The patient was promptly intubated and general anaesthesia was induced. He was admitted to the intensive care unit (ICU) for close monitoring, remaining mechanically ventilated for respiratory support. The patient was successfully extubated and discharged from the ICU on the third day without further complications.

This case highlights the critical need for effective communication among team members and rigorous verification protocols when administering potent medications with narrow therapeutic range such as intrathecal morphine. It also underscores the importance of vigilant clinical monitoring and preparedness to manage potential adverse effects associated with medication errors. Ensuring stringent checks and fostering a culture of safety are paramount to prevent such incidents and ensure patient safety. Further education and training on medication administration protocols are recommended to enhance patient care outcomes.

Over the last 20 years,video assisted thoracic surgery(VATS) become the treatment of choice in multiple chest related illnesses.Usually,VATS requires general anaesthesia with the selective intubation.However,for patients with severe health conditions,or an increased risk of complications from anesthesia,general anesthesia might not be a suitable option.In these cases,VATS can be performed using local anesthesia,allowing the patient to remain awake and without the need for a breathing tube.Compared to traditional VATS with general anesthesia,Awake VATS (AVATS) boasts demonstrably shorter surgery times,less complication and hospital stays

A 68-year-old male patient with known comorbidities of hypertension,and laryngeal cancer was taken into operation for VATS left upper lobectomy.In addition to simple monitoring methods,the patient was monitored for intra-arterial blood pressure measurement and an epidural catheter was inserted in a sitting position at the 5-6th thoracic level,accompanied by sedation.As a result of loss of resistance at 5 cm,the catheter was advanced 8 cm in the epidural space.The procedure was completed without complications.For the epidural dose,0.5%bupivacaine,0.5%fentanyl and 0.9% saline were used

The patient,who was asked to remain absolutely motionless in life-threatening critical locations,was switched to general anesthesia despite effective analgesia due to the change in respiratory depth.In addition to the epidural dose,the patient was given an induction dose of hypnotics and muscle relaxants

AVATS performed using any method is feasible and effective in patients who are incompatible with general anesthesia due to serious comorbidities and respiratory failure.However,switching to general anesthesia should not be avoided due to requirements such as patient safety and surgical indications

Huntington's disease (HD) is a rare and progressive neurodegenerative disorder characterized by motor dysfunction, cognitive decline, and psychiatric symptoms. There are a limited number of case reports published describing the anesthetic management of patients with HD, which presents unique challenges. This case report describes the management of a patient on the severe stage of HD, who underwent general anesthesia combined with peripheral nerve blocks for the placement of percutaneous endoscopic gastrostomy (PEG) tube.

A 55-year-old female, ASA III, with a known diagnosis of HD presented for the placement of a PEG tube. The preoperative history and physical examination showed a total dependent patient with severe choreiform movements in the extremities, cognitive impairment and a significant decline in nutritional status due to the severe dysphagia. After routine ASA monitoring, induction of anesthesia was performed. Anesthesia was maintained using a target-controlled infusion of propofol. Following the induction of general anesthesia, a bilateral rectus sheath block (RSB) under ultrasound guidance was performed with 10mL of ropivacaine 0.5% on each side.

Throughout the 60-min duration of surgery and anesthetic procedure, the patient maintained hemodynamic stability. The patient was monitored in the postoperative care unit and showed no complications and did not require additional analgesia.

This case highlights the importance of a tailored anesthetic approach in patients with HD undergoing surgical procedures. The use of general anesthesia in combination with peripheral nerve blocks can provide effective anesthesia and analgesia while minimizing the risk of adverse outcomes.

ESP block is a relatively new technique that has been used in analgesia for breast and thoracic surgeries. The ESP technique is performed by injecting local anesthetics into the space between the transverse processes and spinous processes of thoracic vertebrae. It is associated with a reduced need for postoperative opioids and improved postoperative recovery. This block could be an effective and safe technique for intra- and postoperative analgesia, avoiding the risks of general anesthesia.

What is described in this article is a report of two similar cases that required relatively urgent surgery in the presence of a full stomach.

Both patients progressed satisfactorily during the intraoperative and postoperative period, did not require extra doses of local anesthesia or narcotics, and were discharged the next day with adequate pain control.

We support this technique as a useful alternative for performing breast surgery without the need for general anesthesia, either with sedation or anxiolysis. We consider that there are areas of opportunity to develop for a different approach in these cases, since the breast has a complex innervation. Although an alternative option could be to add local infiltration at the surgical site by the surgeon, in these cases we did not notice hemodynamic variables during the first surgical incision indicative of increased nociception; However, this plugin is a viable option.

Ultrasound (US) guidance has modified regional anesthesia techniques. In the axillary brachial plexus block, US-guided technique targets terminal branches in the upper arm lateral to the pectoralis major, while the landmark-based technique involves perivascular needle insertion deep in the axillary fossa. Despite the differences, no study has analyzed and compared injectate spread between the two techniques.

Eighteen injections were performed on nine fresh human cadavers. Nine were using the landmark-based and 9 the current US-guided technique. In the landmark technique, insertion point was deep in the axillary fossa under the pectoralis major, directing the needle towards the contra-lateral shoulder. In the US-guided technique, the needle was inserted in the upper arm lateral to the pectoralis major, targeting the musculocutaneous, median, radial, and ulnar nerves. A 50 mm 22G nerve block needle was used and 20 ml of saline with 0.02% methylene blue was injected. After the injections, blunt anatomical dissection was performed to visualize spread.

In the landmark-based technique, complete staining of the brachial plexus fascicles and axillary nerve was observed in 89% of the cases (8 out of 9). In the US-guided method, fascicle staining was considerably lower: in 11% of cases the lateral fascicle was spared; in 22% the medial fascicle; and in 56% the posterior fascicle and axillary nerve. All targeted terminal branches (100%) were stained.

Insertion point, needle direction and injectate distribution significantly differ between the two techniques. US guidance allows for selective injection of terminal branches with less proximal brachial plexus spread.

Traditionally, in our hospital, forefoot interventions have been performed by ultrasound-guided locoregional anesthesia, as a sciatic-popliteal neural block, combined with transartorial saphenous internal block. The purpose of the saphenous block is to avoid the discomfort derived from the use of the ischemia cuff that is placed above the ankle. And it is precisely the need for this blockade that we question in this work.

We selected a group of 50 patients from those who were going to undergo forefoot surgery. All of them underwent anxiolysis with Midazolam 7.5mg (pre-block), and Midazolam 1mg IV + Fentanyl 50mcg IV (post-block). Only the sciatic-popliteal was performed, warning them of the possibility of discomfort in relation to the ischemia cuff, and that they should notify us in case they perceived this discomfort, so that we could correct it. Precaution was taken to place the ischemia cuff as distal as possible. We counted the number of patients who required IV analgesic rescue to finish the intervention comfortably.

Only 7 required IV rescue, due to discomfort derived from the ischemia cuff. In addition, 2 patients also needed it, but it was due to failure of the sciatic-popliteal block.

It seems reasonable to question the need for saphenous block in this type of surgical intervention, since most patients do not seem to need it. 1. Absence of discomfort for the patient of the second puncture. 2. Minimization of the potential risk of iatrogenesis 3. Shorter time to perform the anesthetic technique. 4. Economic savings

Supraclavicular brachial plexus block is frequently performed for surgery of the upper limb distal to the shoulder. Possible complications include pneumothorax, phrenic nerve blockade, vascular punctures, intravascular injection, recurrent laryngeal nerve blockade and Horner’s Syndrome. The latter is a rare complication which arises from local anesthetic spread to the ipsilateral cervical sympathetic chain.

Case report.

A 32-year-old female, classified as American Society of Anesthesiologists physical status I, presented to the operating room for surgical treatment of a diaphyseal fracture of the distal phalanx of the third finger of the left hand, sustained during a surfing accident. The patient underwent osteosynthesis of the distal phalanx with Kirschner wires under regional anesthesia and light sedation. A supraclavicular brachial plexus block was performed under ultrasound guidance with 23 mL of 0.75% ropivacaine. The block took full effect approximately 30 minutes after local anesthetic injection and the block distribution was adequate. Approximately 1 hour after the performance of the block, at the end of the surgery, the patient developed anisocoria, with miosis of the left eye, ptosis and anhidrosis, findings indicative of Horner's Syndrome. The symptoms resolved with regression of the nerve block over less than 24 hours. There were no further complications.

Supraclavicular brachial plexus block is a safe and effective technique for upper limb surgery. Horner’s Syndrome is usually a benign and self-limited complication which has been reported with an incidence of approximately 1% after supraclavicular brachial plexus block.

This systematic review and meta-analysis aims to compare the pain-related and functional outcomes of liposomal bupivacaine (LB) versus plain local anesthetic (LA) for adductor canal block (ACB) in adult patients undergoing knee surgery.

Studies were evaluated in major electronic databases from inception to March 2023, with a search rerun in April 2024. Studies involving additional surgery areas or comparing periarticular infiltrations with ACB were excluded. The study protocol was registered with PROSPERO: CRD42022376835. The primary outcomes were pain scores and opioid consumption in the first 24 hours postoperatively. Secondary outcomes included length of hospital stay (LOHS), pain scores at different time points post-surgery, and associated complications.

Ten trials with 2847 patients (LB=1873, plain LA=974) were included. LB was associated with lower pain scores at 24 hours (SMD = -0.27; 95% CI -0.45 to -0.09; p = 0.003), 48 hours (SMD = -0.34; 95% CI -0.42 to -0.28; p <0.00001), and 72 hours (SMD = -0.30; 95% CI -0.45 to -0.15; p=0.0001). Oral morphine equivalent dosage was lower in the LB group at 24 hours (SMD = -0.48; 95% CI -0.92 to -0.03; p = 0.04). There was no significant difference in LOHS between groups (SMD=0.09 hours; 95% CI -0.02 to 0.20; p=0.12). No significant complications were observed. The overall quality of evidence was low to very low for all outcomes.

While LB showed statistically significant improvements in pain scores and opioid consumption compared to plain LA, these did not translate to clinically meaningful benefits.

Peritoneal dialysis (PD) is an established method for renal replacement therapy in patients with end-stage renal disease (ESRD) who may pose significant anaesthetic challenges due to multi-system co-morbidities with organ dysfunction.

Our patient is a 82 year old gentleman with ESRD secondary to hypertension, hyperlipidemia, diabetes and aortic valve replacement on long term warfarin. With the external oblique, internal oblique and transversus abdominis muscles visualized using ultrasound at level of anterior axillary line between 12th rib and the iliac crest, a single shot right-sided posterior TAP block was performed with an insulated 21Gauge stimuplex needle using “in plane” technique. 20ml of 0.5% Ropivacaine was deposited between internal oblique and transversus abdominis after confirmation of negative aspiration. The patient tolerated the surgery well, with no complaint of pain or additional oral analgesia required 24hours after procedure. No complications such as infection, haematoma or local anaesthetic related toxicity were documented.

Use of TAP block has been proven to be an effective technique for surgery involving anterior abdominal wall. TAP block allows sensory blockade of lower abdominal wall including analgesia of skin, muscles and parietal peritoneum of the anterolateral abdominal wall and avoid GA in these patients. It also provides some analgesia during early post-operative stage and helps reduce postoperative opiate requirements and opioids-related side effects.

US-guided posterior TAP block is an effective method and should be considered an anesthesia technique of choice for PD catheter placement in ESRD patients with major comorbidities.

Ornithine transcarbamylase (OTC) deficiency is the most common genetic disorder of the urea cycle. These disorders are characterized by an inability to metabolize ammonia into urea, leading to hyperammonemia with variable physiological consequences and presenting important anesthetic challenges, especially the perioperative prevention of hyperammonemia and management of its consequences should it occur. Idiopathic scoliosis (IS) is the most common spinal deformity requiring surgical treatment.

This paper presents a case of a 15-year-old female with OTC deficiency who underwent spinal fusion for IS. The chosen anesthetic strategy was a combined anesthesia with total intravenous general anesthesia using target-controlled infusion pumps, an erector spinae plane block using ropivacaine, and a multi-pronged approach to ensure metabolic control while avoiding hyperammonemia.

The existing literature regarding major surgery in patients with OTC deficiency is sparse, and this paper provides one of the first case reports of a scoliosis correction surgery, as well as one of the first descriptions of prolonged propofol infusion and locoregional anesthesia with an erector spinae plane block in this context.

The erector spinae plane block with ropivacaine is a safe and efficient option for perioperative pain management in the context of both idiopathic scoliosis and metabolic disorders such as OTC deficiency.

A 62-year-old male underwent bilateral medial unicompartmental knee arthroplasty in a day surgery unit for grade IV osteoarthritis. Prior to the surgery, he had received conservative treatment in the community, including regular naproxen and paracetamol analgesics. This case report highlights the use of an effective peripheral nerve block technique for bilateral unicompartmental knee arthroplasty.

General anaesthesia was administered according to the patient's preference, comprising alfentanil 1 mg, propofol 150 mg, and rocuronium 100 mg. Additionally, dexamethasone 9.9 mg, ondansetron 4 mg, cefuroxime 1.5 g, and tranexamic acid were administered as per local protocol. Subsequently, a bilateral ultrasound-guided peripheral nerve block was performed, employing maximum safe doses of local anaesthetic. The sequence of nerve blocks performed was as follows: Superomedial genicular nerve, Superolateral genicular nerve, Inferomedial genicular nerve, Nerve to vastus intermedius, IPACK, and Distal femoral triangle targeting the nerve to vastus medialis and saphenous nerve. Local infiltration to the wound by the surgeon was also carried out. The surgical procedure lasted for 3 hours, during which the patient received a total of 5 mg of morphine. Postoperatively, the patient's analgesic regimen prescribed according to local protocol, comprising regular paracetamol, regular oxycodone S/R 10mg twice daily (at 0800 and 20:00), and oxycodone I/R 10mg as needed.

The total morphine usage (see analgesia and pain score timeline below) was as follows: preoperatively 0 mg, intraoperatively 5 mg, and postoperatively until discharge 0 mg.

The peripheral nerve block technique routinely employed by the author demonstrates its efficacy in bilateral unicompartmental knee arthroplasty.

Spinal anesthesia is commonly used for lower limb procedures, its duration may be limited with potential complications due to high doses of local anesthetic. This article describes the technique and experience of using suprainguinal fascia iliaca compartment block(FICB) as an adjunct to spinal anesthesia in an elderly patient undergoing lower extremity surgery.

The case presented involves an 81-year-old female undergoing hip surgery,where the block was performed prior to spinal anesthesia. Despite the unexpectedly prolonged surgical duration of approximately 5hours,the patient remained comfortable, and the surgery was completed without complications.

Subarachnoid block for provision of surgical anesthesia generally lasts between 2to3 hours with a dose-dependent local anesthetic-related adverse effects. This may hinder the utility of spinal anesthesia in complex cases where extended surgical duration may be expected. The continuous spinal anesthesia and combined spinal-epidural(CSE) are useful techniques to provide consistent perioperative anesthesia with precise titration of anesthesia levels. However, this presents with risk of accidental dural puncture with CSE,post-dural puncture headache and inadvertent drug errors with a spinal or epidural catheter. The judicious use of other adjuvants alongside local anesthetics offers advantages in extending the duration of anesthesia by a modest increment. The integration of spinal anesthesia with FICB is a promising strategy to extend block duration, reduce peroperative opioid requirements and enhance patient outcomes.

FICB is a safe anaesthetic technique for the perioperative management of hip fracture patients and may present synergistic effect when combined with neuraxial anaesthesia and may prolong the duration of regional anesthesia during unexpectedly prolonged surgery.  

Regional analgesia and anesthesia for shoulder disarticulation can be achieved by sensory blockade between C4 and T4 dermatomes . Here, we present a report of a patient with severe upper extremity pain and poor respiratory function who underwent unilateral shoulder disarticulation using regional blocks for surgical anesthesia.

An 80-year-old woman presenting with angiosarcoma associated with lymphedema was admitted. Due to the large size of the tumor and intractable pain, shoulder disarticulation surgery was planned. Considering the comorbidities of the case (chronic pulmonary disease, hypertension) we attempted to perform surgery under regional anesthesia. Written consent was obtained after informing the patient about the procedures to be performed and published. We performed the bilevel thoracic intertransverse process (ITP) blocks at the level of the T1/T3 transverse processes in addition to the superficial cervical and interscalene brachial plexus blocks (Figure).

Thirty minutes after the injections, the sensory blockade was assessed by the pinprick method in the C4 to T4 dermatomal areas. Amputation was performed through the shoulder joint, and the humeral head was disarticulated from the glenoid in the lateral decubitus position . The patient remained conscious during the operation (90 min). The average NRS score within the first 24 hours was 2 to 10 (range, 1–4).

The present report demonstrated that the combination of cervical plexus,interscalene and ITP blocks can be used as an alternative method to general anesthesia for shoulder disarticulation surgery in comorbid patients. Further prospective studies are needed to evaluate the feasibility of this approach.

Utility of Peripheral Nerve Blocks Can reduce the effects of general anesthesia on Climate Change.

A cross-sectional study can provide information for the following points.

PNB'S Regional Anesthesia promotion can reduce the effects of general anesthesia on Climate Change significantly.

Title: Promoting Regional Anesthesia Utilizing Peripheral Nerve Blocks to Mitigate General Anesthesia Use and Address Climate Change: A Systematic Review Abstract: The utilization of regional anesthesia, particularly through peripheral nerve blocks (PNBs), offers a promising avenue to reduce reliance on general anesthesia and mitigate its environmental impact on climate change. This systematic review examines the current literature to evaluate the efficacy of PNBs in decreasing the utilization of general anesthesia and its associated environmental consequences. By exploring the clinical effectiveness of PNBs and their potential to minimize the consumption of general anesthetics drugs and gases, this research aims to provide insights into sustainable anesthesia practices. The findings underscore the importance of regional anesthesia promotion as a viable strategy to reduce greenhouse gas emissions and mitigate the healthcare sector's contribution to climate change. Through collaborative efforts among healthcare professionals, policymakers, and environmental advocates, the widespread adoption of regional anesthesia techniques can contribute significantly to both patient care and environmental stewardship.

The nerve to vastus medialis (NVM) contributes to the innervation of the knee capsule through the intramuscular, extramuscular, and deep genicular nerves. This nerve can be identified and blocked using dynamic ultrasound scanning in the distal femoral triangle. However, do all anaesthetists routinely search for and block this nerve during the distal femoral triangle block?

This project surveyed 27 anaesthetists (7 consultants, 17 registrars, and 3 core trainees) regarding their practice of distal femoral triangle block. A sonoanatomy picture capturing the NVM and saphenous nerve in the distal femoral triangle region was obtained from a staff volunteer and saved on an iPad (image 1). Each anaesthetist was asked to draw their needle trajectory and circle the nerve structures on the iPad image as if they were performing the block in real time.

Out of 27 participants, 23 (85%) correctly delineated circles around the saphenous nerve, while only 5 (18.5%) accurately marked the NVM. Additionally, 3 (11%) participants drew a needle trajectory passing through the NVM.

The majority of participants did not target the NVM as part of their distal femoral triangle block. A minority of participants passed their block needle through the nerve, which could lead to nerve damage in clinical practice. To enhance awareness and safety, we introduced an educational poster illustrating the sonoanatomy of the NVM (image 2) and integrated it into a formal teaching course (Plan A blocks) in our department.

Rib fractures occur commonly in polytrauma patients and close to one third develop secondary pulmonary complications. This study aims to compare the analgesic efficacy between ultrasound guided erector spinae (ESP) versus paravertebral block (PVB)

A retrospective analysis of patients with rib fractures that presented to our institution from 2020 to 2023 who either underwent ESP or PVB block was performed. Basic demographics, VAS pain scores before and after intervention, presence of sensory block and potential complications were collected.

We analysed 14 patients which consisted of 12 males and 2 females who had a median and average age of 47.0 and 50.1 years old respectively. On average, 5 ribs were fractured and there were 6 ESP and 8 PVB blocks performed. For patients who underwent ESP block, there was a decrease in VAS scores from 7.6 ± 1.1 to 4.0 ± 1.5, p < 0.018. For PVB block, there was a decrease in VAS scores from 5.3 ± 0.8 to 2.8 ± 0.2, p < 0.009. Investigating the presence of a sensory block, PVB demonstrated superiority in producing a sensory block in 87.5% and ESP in 50% of cases. However, there was 1 PVB block that required conversion to epidural and another patient who underwent ESP that needed supplemental PCA fentanyl.

Both techniques were effective in reducing pain scores but PVB block demonstrated a trend towards lower pain scores, albeit without statistical significance. PVB group had superiority in producing a dermatomal sensory block.

A 64-years-old female with a history of hypertension was scheduled for right knee arthroscopy due to ruptured meniscus. Postoperatively she received analgesic saphenous nerve blockade at the level of adductor canal.

Following spinal anesthesia at L3-4 interspace, using 27G Whitacre needle and chloroprocaine, patient received analgesic nerve blockade at the level of adductor canal using 10ml of 0.25% levobupivacaine.

24 hours post-surgery patient started to feel burning pain in the saphenous nerve dermatome below knee. Pain was sharp, localized around medial malleolus, provoked with leg movement and lasted couple of seconds. 20 days post-surgery pain was still present but diminished in frequency and intensity. EMNG of femoral and saphenous nerve showed absence of signal along saphenous nerve. Right leg MR showed intraneural edema in 11cm long segment from medial condyle downwards.

Saphenous nerve entrapment as a consequence of regional anesthesia at the level of adductor canal has not yet been described in literature. Damage to the infrapatellar branch of saphenous nerve is known complication of knee arthroscopy but symptoms presented here did not correlate with infrapatellar branch injury, so the initial conclusion was that they originated from main branch entrapment. MR was able to precisely locate type and location of injury so it should be the method of choice in this type of injury. Assumption is that high tourniquet pressure entraps the nerve and prevents its additional axial, longitudinal mobility. In the case of additional leg movement after tourniquet placement, axial nerve extension injures the tourniquet entrapped nerve.

The case demonstrates that ultrasound-guided nerve block with sedation is a safe and effective alternative to general anesthesia for upper extremity surgery in patients with limited neck mobility due to a halo device. This technique avoids the risks of general anesthesia and potentially reduces costs while keeping patients comfortable throughout the procedure.

A 21-year-old man with a halo device fixing a cervical spine fracture needed surgery for his fractured humerus. Due to the halo device limiting neck movement, regional anesthesia with ultrasound-guided supraclavicular nerve block was chosen. After sedation with midazolam and fentanyl, the doctor injected ropivacaine with ultrasound guidance to numb the arm. Dexmedetomidine was added for continuous sedation. The surgery lasted 2.5 hours, and the patient recovered well with pain medication.

This case report shows that ultrasound-guided nerve block with sedation is a safe and effective alternative to general anesthesia for upper extremity surgery. It's particularly valuable for patients with limited neck mobility, like those wearing a halo device. The patient in this case tolerated the surgery well with minimal sedation, stable vitals, and minimal postoperative discomfort, all controlled with medication

Ultrasound-guided supraclavicular nerve block with dexmedetomidine sedation emerged as a safe and effective alternative to general anesthesia for upper extremity surgery in this case. It avoids the risks of general anesthesia for patients with vulnerable cervical fractures. This regional block technique potentially reduces anesthesia costs while providing adequate pain control. Additionally, dexmedetomidine keeps patients comfortable and cooperative during surgery by offering mild sedation and pain relief.

Peripheral nerve blocks provide anesthesia and pain management benefits but carry approximately a 3% risk of post-operative neurological symptoms (PONS). The risk of long term injury is 2-4 per 10000. Factors which contribute to PONS include surgical, anesthetic and patient factors like positioning, tourniquet ischemia, pre-existing deficits, diabetes and receiving a nerve block. Identifying these risk factors for PONS is crucial, but our institution was limited by inconsistent reporting due to a lack of a standardized referral system. We therefore undertook a Quality Improvement Project (QIP) to address this gap in our practice. We aimed to develop a system to capture, track and manage PONS cases after peripheral nerve blocks at our institution.

A multidisciplinary team (anesthesiologists and informaticians) designed an electronic PONS reporting form within the Electronic Patient Record (Cerner PowerChart(R)), adapting the RA UK pathway to our needs. User feedback and discussions refined the form for usability and comprehensiveness.

This collaborative approach led to a user-friendly electronic PONS reporting form within the existing clinical workflow. The form facilitates PONS case tracking, enabling future research into risk factors, incidence, and patient management.

A standardized user-friendly electronic PONS reporting system will improve patient outcomes through better case reporting, follow-up and management. Creating a database of PONS in an institution where a high-volume of nerve blocks are performed is vital for patient safety. This approach can be valuable in circumstances where a high-volume of nerve blocks are performed across multiple sites and for multiple surgical services, ultimately enhancing patient safety.

Blocks of individual nerves in the forearm, is well established, either a landmark or ultrasound guided approach. A circumferential spread of LA might result in an adequate or inadequate block. Based on a cadaveric-injection study, we aspire to investigate the spread pattern and anatomic-barriers that would impede the flow of injectate

In 2-THEIL based cadavers and four specimens, a total of 12-injections (one each in median, ulnar and superficial-radial nerve) were performed. The primary aim was to evaluate the spread pattern of the injected latex in all three nerves. The secondary aim was to investigate the diffusion of injectate in muscles, para-neural tissue, epineural tissue and longitudinal extent of the spread of latex. Technique- A single puncture block was administered with 50mm needle under a linear probe with an out of plane approach, at 6cm distal to the elbow crease. A 3ml latex was injected each at median(blue), radial(green) and ulnar(green). At 24th-hour forearm dissection was executed from above the elbow crease up to the mid forearm.

Ultrasound-guided injections were performed in the paraneural tissue of all three nerves (4 specimens and 12 injections). Open dissection at 24-hours later revealed spread-pattern as 50%,75% and 50% continuous for median, superficial-radial and ulnar nerve respectively[Table1]. Epineural spread(25%), intramuscular diffusion in the muscle group of median(25%)and ulnar( 75%)occurred respectively

Based on our cadaveric-injection study, we recommend a forearm nerve block at ‘5cm’distal to the elbow crease. We conclude, in the forearm nerves, a non-circumferential, longitudinal spread -pattern is consistent with a ‘3ml’ latex-injection.

Pain management in shoulder arthroscopy is critically important for recovery, rehabilitation, and patient satisfaction. Interscalene block, infiltration anesthesia, suprascapular nerve block, axillary nerve block, and upper trunk block are commonly used in shoulder arthroscopy. This study aims to identify the preferred regional anesthesia practices of anesthesiology and intensive care specialists involved in shoulder arthroscopic surgery in our country.

A 13-question multiple-choice survey was distributed to members of the Turkish Society of Regional Anesthesia (TSRA) in April 2024. This study received approval from the local ethics committee. Participants were queried about their experience with regional anesthesia, preferred analgesic methods, regional anesthesia administration techniques, and postoperative analgesia practices for shoulder arthroscopy.

108 of 690 (12.8%) TSRA members participated. 89 (82.4%) of the participants had more than 60 months of experience with regional anesthesia and 63 (58.3%) of the participants reported having previously attended a course approved by ESRA. For analgesia in shoulder arthroscopy, 92% of participants reported using an interscalene block, 29.6% a suprascapular block, 18.5% a combination of suprascapular and axillary blocks, and 11.1% an upper trunk block. In postoperative analgesia, paracetamol combined with simple analgesics, tramadol, patient-controlled analgesia, and peripheral nerve catheter implantation were preferred by 53.7%, 39.8%, 37%, and 30.6% of participants, respectively. Furthermore, 71.3% of the respondents administered regional anesthesia under ultrasound guidance, while 41.7% used both ultrasound and nerve stimulation needles.

Anesthesiologists specializing in orthopedics exhibit a wide variation in their preferences for intraoperative and postoperative analgesic methods during shoulder arthroscopy

Wrong-side blocks (WSBs) are a rare but serious complication in regional anesthesia. Anesthesia providers at our institution performed an average of 5,000 regional blocks annually across four block rooms. Acknowledging the grave repercussions of inadvertent WSBs, this quality improvement project focuses on investigating contributing factors and proposes preventive strategies, aiming to enhance patient safety.

An anonymous survey assessed WSB occurrences and near-miss events within our institution over the past three years. We analyzed the data to identify potential root causes.

Despite safety protocols, four WSBs occurred, all deemed avoidable. Time pressure (32%), increased time between checklist and block (20%), change of assisting nurse (20%), checklist by another person (16%), and change of block performer (12%) were identified as contributing factors. Notably, one WSB resulted from unfamiliar prone positioning practices affecting landmark and ultrasound usage.

Factors such as time constraints, communication breakdowns, and procedural variations potentially contribute to the risk of WSB incidents. To mitigate these, we advocate for the implementation of a standardized safety checklist, documented electronically. It is imperative to allocate sufficient time for each procedural block to alleviate time constraints. Additionally, improving communication through handoff protocols and reducing the duration between checklist completion and block execution is paramount. Furthermore, comprehensive WSB prevention training should be imparted to all block room members. These strategies are designed to minimize the occurrence of WSB incidents and optimize patient safety.

Rehabilitation after total knee arthroplasty (TKA) routinely starts immediately after surgery on the postoperative ward and therefore requires adequate analgesia. Peripheral nerve block is associated with improved early analgesia and ambulation which is significant in patients undergoing unilateral total knee arthroplasty. This study mainly determined the impact of peripheral nerve block on post operative pain and early ambulation of patients who underwent unilateral total knee arthroplasty.

The researcher conducted a retrospective cohort study of patients who underwent unilateral TKA surgeries from the year 2017 to 2021 in a single institution. The sample size of 18 subjects per group was computed with 20% allowance, with a total sample size of at least 36. Patients were selected based on the inclusion and exclusion criteria and divided into two (2) groups: those who received peripheral nerve blocks and neuraxial techniques.

We found the use of PNBs to be associated with significant lower numerical pain rating scale upon movement at 24th and 48th hour post-operatively with p values of < 0.05. Moreover, patients were also able to ambulate earlier, with an increase in knee range of motion as well as walking with assistance at 24th hour and without assistance at 48th hour post-operatively compared to those who received neuraxial techniques.

Therefore, PNBs are effective in reducing post-operative pain and promoting early ambulation in patients undergoing unilateral TKA surgeries. Incorporating PNBs into pain management protocols for TKA procedures may lead to improved patient outcomes and faster recovery.

This review was undertaken to assess perioperative management and outcomes after primary total knee replacement.

Retrospective data collection from 28 patients undergoing primary knee arthroplasty. Data collection included patient demographics, ASA, BMI, pre-operative opioid use, anaesthetic technique, tourniquet use, post-operative analgesia regime, assessment of pain and mobility on POD 1 and 3 and duration of post operative regional analgesia.

BMI and chronic opioid usage were lower than historical data numbers. 93% patients had single shot spinal, 82% underwent sedation and 18% had a GA. All patients had an adductor canal catheter sited with an infusion post operatively of 0.2% ropivacaine. 96% cases had surgical LIA of various volumes up to 100ml ropivacaine 0.2%. Average pain score at rest on POD 1 was 3.29, ranging from no pain (11%), to mild pain (71%), moderate (11%) and severe (7%). 57% could mobilise 5m on POD1. Pain scores increased on mobilisation with 32% reporting moderate and severe pain. By POD 3, 6 patients (21%) were already discharged. Of the remaining patients, 55% reported mild pain. 71% mobilised 20m on POD3. Pain scores on movement were predominantly moderate (50%) and severe (23%).

2023 results demonstrate exciting progress in total knee replacement perioperative care at Sir Charles Gairdner Hospital, with 21% of patients discharged home by POD 3. This may be as a result of improved patient selection for total knee replacement. The most common anaesthetic technique for TKR in our hospital is a single shot spinal with sedation and an adductor canal catheter.

The serratus anterior plane block (SAPB) is used for postoperative analgesia in thoracic surgery and minimally invasive cardiac surgery (MICS). Although a single injection of the SAPB 0.4 mL/kg local anesthetic reportedly affects T2–T9, the distribution of the infused local anesthetic from the SAPB catheter remains unexplored. Thus, this study aimed to use imaging to evaluate the distribution of contrast agents injected via SAPB catheters in patients undergoing MICS.

This retrospective observational study included patients who underwent elective MICS. The SAPB catheters were preoperatively inserted into the caudal rib of the surgical site near the middle axillary line. Postoperatively, we conducted X-ray imaging sessions to assess catheter positioning and local anesthetic distribution. A mixture of 10 mL of iohexol and 10 mL of 0.75% ropivacaine was injected through the catheter, with four X-ray sessions conducted after each 5 mL injection of the mixture.

Twenty-seven patients were enrolled in this study; mitral valve surgery was the most common procedure (48%). The median (interquartile range) number of intercostal levels of contrast spread was 2 (2.0–3.0) at 5 mL, 2.5 (2.0–3.0) at 10 mL, 2.5 (2.3–3.0) at 15 mL, and 3 (2.5–3.3) at 20 mL. The contrast spread range was significantly larger at 20 than 5 mL (p=0.002).

The longitudinal extent of contrast spread was greater after the injection of 20 versus 5 mL of SAPB. Based on these findings, the use of serial injections via a SAPB catheter may affect a relatively smaller area than the use of a single SAPB injection.

Since its introduction, intercostal cryoanalgesia in NUSS surgery for pectus excavatum repair has gained popularity for its benefits in long-term pain control, shorter hospital stays, and reduced opioid use in pediatric patients. However, potential risks for pediatric patients require further attention. This study aims to shed light on a significant but underreported complication: massive pleural effusion secondary to intercostal cryoablation.

Our case involves a 13-year-old patient who underwent percutaneous cryotherapy on the intercostal spaces from T7 to L3 bilaterally, 72 hours before surgery. This involved two cycles of freezing at -70°C for 2 minutes, with a 30-second thawing period for each space. The patient then underwent surgery with an additional spinal erector block. The postoperative course was smooth, and after 7 days he was discharged.

Three weeks after, the patient returned to the hospital with a mild fever and shortness of breath. Examination revealed a right-sided pleural effusion of 11 cm with atelectasis in the middle and lower lobes. Thoracoscopy and drainage were performed, leading to recovery and discharge 10 days later. Biochemical analysis indicated an inflammatory exudate.

Although direct-vision cryoanalgesia has a documented 50% rate of pleural effusions/pneumothorax, there is less information on the percutaneous approach. This method, regardless of the mode of application, appears to cause soft tissue injury near the probe, potentially leading to fluid accumulation and symptomatic effusions. To reduce risks, cryoanalgesia protocols should be optimized, ensuring proper freezing and thawing times, considering one-lung ventilation, employing direct-vision techniques when possible, and maintaining careful follow-up by anesthesiologists.

Performing non-obstetric surgery on pregnant patients is a challenging task for non-obstetric anaesthesiologists. The primary objective is to ensure safety of both the mother and the fetus. It is crucial to avoid the use of dangerous drugs, hypoxia, and hypotension while maintaining adequate uteroplacental perfusion. Regional anaesthesia plays significant role in reducing neuroendocrine response to stress and the need for opioids and systemic analgesics.

Case report: A 21-year-old pregnant patient in her 37th week of gestation was admitted for surgery on a fractured ankle joint. The anaesthesia plan included administering a femoral and popliteal nerve block with moderate sedation. The patient was placed in lateral position, and an ultrasound-guided popliteal block was performed. The block included the tibial nerve, and the common peroneal nerve, and 15ml of levobupivacaine 0.5% and 10ml of lidocaine 1.3% were injected. The patient was then placed in supine position, and a proximal saphenous block was performed by infiltrating 10 ml of levobupivacaine 0.5%. Blockade of the saphenous nerve achieved anaesthesia for cutaneous medial leg and ankle joint capsule. The combination of these regional block techniques provided complete anaesthesia below the knee.

The multidisciplinary approach is essential for the safety of pregnant patients undergoing non-obstetric surgery. This team should include an obstetrician, an anaesthesiologist, a surgeon, and a perinatologist. The anaesthesia and postoperative analgesia should be well-planned to ensure the safety of both the mother and the fetus. A popliteal nerve block with addition of a femoral block provides adequate anaesthesia for ankle surgery.

Undertaking procedures under regional anaesthesia (RA) avoids the risks, side effects and longer recovery associated with general anaesthesia (GA). There is a regular upper limb plastic surgery list at Whiston Hospital where patients have procedures under RA alone with no sedation, predominantly a brachial plexus block plus targeted forearm blocks.

Data has been collected (with audit department approval) from a six month period in 2023, including timings, operations, type of blocks, and follow up patient satisfaction questionnaires. Theatre timings were also recorded for patients having GA for similar procedures on alternate lists over the same period.

Patient questionnaires showed 78% rated the experience a maximum 5/5 and would recommend. There was no nausea or vomiting, and 100% felt their concerns were addressed and understood the information (table 1). Comparing timings, patients having RA had less time between arrival in the anaesthetic room and operation starting than GA, and much shorter time between operation finishing and returning to the ward (table 2).

A dedicated list under RA allows for streamlining of processes and better patient preparation. There is a perception that patients prefer GA but our satisfaction data shows that RA is favourable when well prepared. Our timings data demonstrates that even for a teaching list, patients can be ready for surgery quicker on average than with a GA. With no need for step-down recovery, they return to the ward quicker allowing for earlier discharge home.

The IPACK block is the first choice for good analgesia with better motor sparing than sciatic or tibial nerve blocks after total knee arthroplasty (TKA). We also argue that the popliteal plexus block (PPB) provides sensory block of the posterior knee capsule when local anesthesia is extended from the adductor hiatus to the popliteal fossa.

20 patients undergoing TKA were retrospectively reviewed. Patients received 15 mL of 0.25% levobupivacaine for IPACK or PPB with a multimodal analgesia protocol that included an adductor block. The primary outcome was dorsiflexion muscle strength 6 hours after the nerve block procedure, and we evaluated the value as a percentage of the preoperative baseline. Secondary outcomes were time to discharge criteria, pain scores, use of additional analgesics, pain scores, and knee flexion range in the operative knee.

The percentage of dorsiflexion strength at 6 hours postoperatively was 79±19% in PPB versus 63±23% in IPACK (mean±SD, difference 15%; 95% CI: -34 to 2%; p = 0.08). Other outcomes were not statistically different between the two treatment groups.

Our results suggest that PPB and IPACK provide no difference in dorsiflex muscle strength. However, PPB tends to preserve dorsal motor function, suggesting less potential for anesthetic infiltration around the peroneal nerve than IPACK. We believe this trend warrants a larger sample size and a prospective, double-blind, randomized controlled trial to draw the proper statistical conclusions, and a clinical study is currently underway.

The use of peripheral nerve blocks (PNB) are common for outpatient complex foot and ankle surgery. These can either be single shot (sPNB) or continuous via a catheter (cPNB). They have been shown to reduce opioid consumption and post surgical pain. These commonly are popliteal (PoNB), femoral (FeNB) or adductor canal (AdNB). The purpose of this study was to determine the use of opioids after sPNB in complex foot and ankle surgery at the Tertiary Royal National Orthopaedic Hospital and determine whether patients may benefit from cPNB.

This was a prospective audit. 20 patients who had received sPNB undergoing either an (1)ankle fusion, (2)ankle replacement or (3)complex procedures involving calcaneal osteotomies were included. The primary outcome was immediate release (IR) opioid use in the first 24 and 48 hours. The secondary outcomes were length of stay, pain scores and delay to discharge.

18 patients (90%) received both a PoNB and FeNB or AdNB with two (5%) receiving PoNB alone. Nine patients (45%) required IR opioids in the first 24 hours. Three patients (15%) required IR opioids from 24 to 48 hours. Median length of stay was one day, with no delay to discharge secondary to pain.

This has demonstrated that sPNB is an effective method of pain relief for complex foot and ankle surgery. Most patients did not require immediate release opioids, and there were no delays to discharge due to pain. Further studies with a larger sample size are required to determine whether specific patients may benefit from cPNB.

Aesthetic breast surgery is the most common body surgery.Aim is that the procedure itself from induction of anaesthesia to early and late recovery, enables a quick return to daily activities and work.

136 patients divided into two groups underwent breast augmentation in general analgesia.The control group had surgically infiltrated interfascial pectoral nerve block performed through a small puncture incision in the axillary region with application of 5 ml 0,5% Bupivacaine per side to the pectoral muscle region between large and small pectoral muscles.The comparative group had general anaesthesia.Intensity of pain was analysed the first 7 days using NRS.Ethics committee approved.

The greatest progress in reducing pain is observed on the first and second day after surgery, while on day 3 the pain is present minimally more than in previous days. The slight pressure is felt after 5 days in both groups. All patients were able to return to daily activities and work after 7 days postoperatively while avoiding carrying heavier loads and strenuous physical activities.

The pectoral nerve block with Bupivacaine deposited in the layer containing the pectoral nerves between the pectoralis major and pectoralis major muscles decreased pain scores approximately 50% lower than controls during the first 24 postoperative hours decreasing opioid requirements.There were reduction of nausea, vomiting and sedation in the recovery room. Discharge was earlier as well. If future research confirms the effectiveness of these blocks, they could be considered a standard for breast surgery because of their ease of application and relatively low potential of complications.

Awake craniotomy and deep brain stimulation (DBS) procedures require the patient to be awake and appropriate anaesthesia conditions can be provided with a scalp block. These procedures inherently generate some level of pain from local anesthetic injections during scalp block administration. We aimed to reduce the injection pain in scalp blocks using a vibration stimulus.

A total of 56 patients, aged between 18 and 75 years, undergoing awake craniotomy and DBS procedures were included in the study. All patients were administered a loading dose of dexmedetomidine before a scalp block. Local anesthetic injections were applied sequentially to the identically named nerves on the right and left sides of the head. A vibration device was used during the injections on one side, whereas the injections on the other side were performed without a vibration device. Numeric Rating Scale (NRS) score and hemodynamic measurements during each injections, including heart rate and mean arterial pressure were compared between vibrated and non vibrated site.

The NRS scores were significantly lower on the side where vibration was used during scalp block injections (P<0.001). Additionally, both mean arterial pressure and heart rate significantly decreased on the side where vibration was used (P<0.005).

The study showed that using topical vibration during a scalp block can decrease the pain of a local anesthetic injection and maintain hemodynamic stability.

Diaphragmatic eventration, less commonly seen in adults, presents with paralysis, aplasia and diaphragmatic muscle fibers atrophy. Moreso, it´s associated with other respiratory pathologies, presenting challenges to anaesthetic management in order to minimize post-operative complications. We describe the successful anaesthetic management of a patient with diaphragmatic eventration.

A 71 years-old male, ASA-PS IVE, with prior medical history of severe sleep apnea, left hemiparesis, metabolic syndrome and dementia. The patient was schedule for partial hip arthroplasty due to trauma. Prior to surgery, incidental radiological diagnosis of diaphragmatic eventration was made (Figure 1). No further relevant alterations were found in analytical and transthoracic echocardiogram studies. A combined regional anaesthesia comprised of spinal block with 12,5mg levobupivacaine followed by an ultrasound guided suprainguinal fascia iliaca block (FICB) with 30mL of Ropivacaine 0,375% without conservatives.

The perioperative period was uneventful with no ventilatory support needed. In the first 24 hours the patient remained with mild pain, without the need for rescue opioid analgesia. The patient was discharged 5 days after procedure.

Coexisting diaphragmatic and respiratory pathology increase the risk of post-operative respiratory complications associated with general anaesthesia, presenting a challenge to the Anaesthesiologist. In this clinical case, we demonstrate that a combined locoregional anaesthesia can be an effective and safe option. As such the FICB contribute to avoidance the use of opioids and respiratory depression as well as pulmonary complications related to mechanical ventilation. Locoregional anaesthesia constitutes a powerful weapon when approaching patients with complex respiratory pathology, contributing to minimizing post-operative morbidity and mortality.

St Albans City Hospital, part of West Hertfordshire Teaching Hospitals NHS Trust, specialises in elective surgeries like total knee (TKR) and hip replacements (THR). This study assessed pain scores on postoperative days 1 and 2 for TKR and THR patients, along with rescue analgesia requirements and their effect on hospital stay.

We developed an observational questionnaire for postoperative and ward nurses to record pain scores at rest and on mobility. We documented surgery type, anaesthesia, peripheral nerve block (PNB), intraoperative analgesia, rescue analgesia, complications, and hospital stay duration. We benchmarked the ERAS data from our hospital during that period.

Amongst n=67, spinal anaesthesia was preferred in n=56 (n=35 for THR and n=21 for TKR). PNB was preferred in n=1, and LIA was n=48. 69% received unimodal intraoperative analgesia (65% IV Paracetamol alone, 4% IV Morphine alone) and 31% multimodal (in GA). All patients received oral Oxycodone postoperatively. Pain scores were nil on day 0, moderate-severe on day 1 and mild-moderate on day 2. Higher pain scores highlighted discharge delays due to pain (TKR) and mobility (THR), also seen in the ERAS dataset.

Our study suggested introducing PNBs, which was reflected as a new protocol including iPACK and adductor canal block for TKR to aim for day-case arthroplasty, scanning sessions to teach these blocks, standardising pain entry with an NRS scorecard and targeting analgesia on Day 1. We plan to reaudit pain scores by implementing these regional anaesthetic techniques and evaluating their impact on hospital discharge times.

Minimally invasive spine surgery is considered gold standard for the treatment of a multitude of degenerative conditions of the vertebral column. Erector spinae plane (ESP) block is a relatively novel regional anesthesia technique, in which local anesthetic (LA) is injected into the fascial plane between vertebrae transverse process and erector spinae muscles. Analgesia is achieved through cranio-caudal distribution of the LA via the fascia, combined with diffusion of the LA into the paravertebral space. Targets of action are dorsal and ventral branches of the spinal nerves.

We present a 67-year-old woman scheduled for minimally invasive decompression and arthrodesis at the L3-L4 level with XLIF approach. Bilateral ultrasound-guided ESP block was performed at the lumbar level 30 minutes before surgery. 20 mL of 0.25% levobupivacaine was injected on each side using a 20G x 100 mm echogenic needle.

Anesthetic induction consisted of propofol at 2 mg/kg + 150 µg of fentanyl + rocuronium at 0.6 mg/kg. Performance of the ESP block allowed the avoidance of maintenance opioids, either by infusion or IV bolus, throughout the entire 120-minute surgery. The patient showed no clinical signs of neurovegetative response to the surgical stimulus, indicating no need for opioid administration during the intervention. After anesthesia emergence, the patient had satisfactory pain control (EVA score 2), with improvement within 24 hours.

Preoperative performance of a bilateral erector spinae plane block is a potentially advisable therapeutic option for pain control in patients undergoing minimally invasive lumbar spine surgery

SAFIRA (SAFer Injection for Regional Anaesthesia - Medovate Ltd.) is an advanced technology designed to enhance the precision and safety of regional anaesthesia procedures.

As an anaesthetic trainee, I found SAFIRA’s novel pressure sensing needle helpful in proving real-time pressure monitoring feedback, enabling the user to adjust their technique, aiming for optimal needle placement, and reducing the risk of complications, such as intraneural or intravascular injections. With a colour-coded foot pedal or handheld switch system, the user-friendly design of SAFIRA has allowed me to become confident performing various regional anaesthesia procedures with a single operator technique, allowing for quicker, easier and more time efficient procedures.

A survey of anaesthetic trainees within QEHKL, as well as a London and Melbourne hospital, showed 74% believed an injection pressure monitoring system should be available in their hospital. In QEHKL, SAFIRA is available, however only 55% of trainees have used it, of which the majority only used it infrequently, either because it is not readily available (29%), or they do not feel confident using it (39%). 48% found SAFIRA user-friendly, however, only 16% found that it saved time. Finally, an overwhelming 71% found SAFIRA helpful in trying to prevent intraneural injection and nerve damage.

In conclusion, this abstract offers an overview of a trainee’s experience with SAFIRA, emphasising the journey from initial curiosity, to becoming proficient in utilising its features for safer and more precise injections. As well as underscoring the potential benefits of SAFIRA in enhancing patient safety and improving regional anaesthesia outcomes.

The Royal College Of Anaesthetists (RCOA) 2021 curriculum demands Anaesthetists in Training (AIT) be competent in Plan A blocks by completion of training (CCT). Regular practice and ultrasound workshops are pivotal for training in Regional Anaesthesia (RA). To enhance RA training accessibility, we propose initiating a mobile RA club focusing on Plan A blocks and sharing credible online RA resources. Our objective was to gauge awareness of Plan A blocks, preferred RA learning sources, and receptiveness to establishing local Sonoclubs in Northwest hospitals.

A survey comprising 10 questions, including one open-ended query, was distributed to Northwest Anaesthetists, yielding 57 responses over 2 weeks.

Findings reveal over 78% familiarity with Plan A blocks, yet most possess limited experience with upper limb and truncal blocks. Reputable online sources are favoured for individual learning, although nearly 70% do not engage with any online RA platform. Notably, 33% lacked RA training in the past year, while almost all expressed interest in localized RA teaching during hospital rotations.

While progress in RA training and practice is evident in the region, opportunities for improvement persist. We have initiated the dissemination of coded reputable online resources, such as the Regional Anaesthesiology and Acute Pain Medicine YouTube channel, and plan to establish a mobile RA Club. This initiative will leverage advanced regional trainees, rotating to new hospitals with the guidance of local and visiting consultants. A mandatory 3-month regional rotation may be necessary in the future to further enhance RA proficiency.

In patients receiving vitamin-K antagonist treatment, deep nerve procedures should be performed according to the recommendations for neuroaxial procedures. However, the guideline may not be clear for superficial nerve blocks, especially if the INR is above target range.

The present case concerns a 77-year-old female patient under acenocoumarol therapy owing to a double mechanical valve prothesis and chronic atrial fibrillation. Additionally, her medical history includes a tricuspid valvuloplasty, severe pulmonary arterial hypertension, and a restrictive lung disease. The patient was referred from another medical center due to a hematoma in the left lower extremity resulting from a contusion. The hematoma was causing a compartment syndrome, and the INR value was 4.1. In this context, an urgent drainage of the hematoma was indicated, and the anticoagulation was reversed using 10 mg of vitamin K and 1000UI of prothrombin complex. Subsequently, popliteal sciatic nerve block was performed under ultrasound and neurostimulation guidance, with 20 ml of 1% mepivacaine and 0.25% bupivacaine.

The hematoma drainage was successfully performed. During the procedure, a minimal sedation had to be administered as the surgical wound was extended to the medial leg, an area not covered by the sciatic block. Additionally, red blood cell transfusion was required due to significant blood loss.

Peripheral nerve blocks can be administered to patients who are taking anticoagulants. However, tailoring each case by considering patient's characteristics, the target INR, and the nerve block’s characteristics, such as compressibility, vascularization, and potential consequences of bleeding if it occurs, is likely the best practice.

Shoulder surgery can be associated with severe postoperative pain. The shoulder is innervated by both cervical and brachial plexuses. Shoulder arthroscopy is conducted via two or three ports with patient placed on beach chair position. Interscalene brachial plexus blockade is used to provide anaesthesia and analgesia and is considered as the regional technique of choice. Our objective was to present a series of cases of shoulder surgery performed under interscalene brachial plexus block in a tertiary hospital in Qatar.

Following departmental approval, we undertook a retrospective study of all patients undergone shoulder surgery. Data was retrieved from the electronic Patient Record System. Patients’ demographics, type of surgery, mode of anaesthesia and time to first analgesic use were collected.

126 patients have undergone shoulder surgery over 3 years period (2021 – 2023). All patients were assessed in anaesthesia clinic and consented to have interscalene block as a sole anaesthetic. The attending anaesthesiologist performed ultrasound guided interscalene block in a dedicated block room with standard monitoring in place. 20 -30 milliliters of a mixture of levobupivacaine 0.5% and lignocaine 2% was used in all patients based on body weight. Intraoperative sedation was based on patient factors and surgical procedure. All surgical procedures were performed by a single surgeon. Demographic data and data related to type of surgery and mode of anaesthesia are presented in tables.

Interscalene block represent an optimum mode of anaesthesia for shoulder arthroscopic surgery and is associated with lesser opioid use and no reported major complications.

Upper limb tumors are rare diseases, but once diagnosed they require aggressive surgical treatments with a highly painful postoperative period. We reviewed the cases treated in our center during the last 5 years in order to check if the outcomes in postoperative pain management were acceptable or needed improve.

4 cases were treated in our center during this period, of which one was humeral osteosarcoma and the remaining 3 humeral chondrosarcoma. In all these cases, a wide humeral resection and implantation of a megaprosthesis was performed. Combined anesthesia was chosen in all 4 cases (TIVA + ecoguided continuous peripheral nerve block). In 3 cases an interscalene block was performed and in the remaining case a supraclavicular block. Pain level was monitored daily via the VAS scale, as well as the need for opioids and the day of catheter removal.

The catheter was removed between the 4th and 5th postoperative day in 3 cases. In the remaining case, due to an air entry into the circuit and consequent malfunction that caused a VAS level of 6, the catheter was removed on the 6th day. Apart from this fact, the maximum VAS was 2 in all cases and the patients did not require rescue opioids. Pain level from withdrawal to discharge ranged in similar values.

Despite presenting a short series of cases, we believe that the use of peripheral nerve catheters is an excellent option in the perioperative management of pain in this type of procedure.

Phantom Limb Pain (PLP) is a challenge in pacients with amputation surgery; between 50-80% of patients develop PLP after surgery, once it gas appeared requieres a complex managemente with poor pain control, hence recommendations go towards prevention.

87 years old man ASA IV in hemodialysis and Clostridium difficile bacteremia, present a non-revascularizable chronic lower limb ischemia, a supracondylar amputation is proposed. A general anesthesia with laryngeal mask is performed and for analgesia: Femoral Nerve Block with Levobupivacaine 0.25% 15 ml. Ultrasound- Guided Femoral Nerve Catheter is placed with Levobupivacaine 0.125% 5 ml/hour infusion. Chemical neurolysis of stump nerves. NSAID (Paracetamol + Dexketoprofen)

The patient did not requiere rescue analgesics after surgery and VAS was kept under 3 until he left PACU.

Literature supports the use of neuroaxial techniques to prevent PLP, but in this case we declined this approach having in mind the patient comorbilities. Chemical neurolysis of stump nerves and femoral nerve block take in account the physiological periferical changes for a later development of PLP and at the same time a lesser pain score has a better prognosis for PLP, considering the condition of the patient we chose an aggresive approach from the beggining to assure minimun risk with the least systemic repercussion, with this case we show an alternative to the often neuroaxial techniques when they are not a safe option.

Plan A blocks are widely accepted as being essential for trainee anaesthetists. Although RAUK previously published videos of the blocks being performed, they are outdated by 13 years. Our aim is to produce updated videos of the plan A blocks to help educate trainees, improving their confidence with regional anaesthesia.

A survey was distributed to all anaesthetic trainees in Northern Ireland, assessing their confidence levels on a scale from 1 to 10 in performing each Plan A block independently. They were also asked if they felt the current training in regional anaesthesia was adequate and whether they felt locally produced instructional videos for the Plan A Blocks would be beneficial.

A total of 48 trainees responded. Mean confidence across all Plan A blocks was 4.6, core trainees scoring significantly lower (2.9) than speciality trainees (6.1). The mode of the data set was 1, representing 24% of responses. Trainees were least confident at interscalene (2.5), axillary (3.2), erector spinae plane (3.4) and rectus sheath (4.4). Trainees were most confident with femoral (7) followed by popliteal sciatic (5.8) then adductor canal (5.65). 75% of trainees felt that current educational resources were inadequate. 90% believed they would benefit from locally produced instructional videos.

Trainees in Northern Ireland lack the requisite confidence to independently perform the Plan A blocks. As expected confidence increases as they progress through training but overall confidence at higher levels is still not adequate. The introduction of locally produced instructional videos may complement their current training and improve confidence levels.

We present the case of an eight-year-old male, ASA III, with bilateral hip dislocation scheduled for bilateral hip reconstructive surgery (Klisic Procedure) planned for two different surgical times. His medical history included spastic quadriparesis secondary to traumatic brain injury at ten months, hydrocephalus managed with a ventriculoperitoneal shunt, epilepsy, and a severe platelet storage pool disorder

Surgery was performed under general anesthesia with non-invasive and invasive monitoring (arterial line and central venous catheter), coagulation status monitoring with TEG, and avoidance of neuraxial techniques. The patient received a tranexamic acid infusion during both surgical interventions. For his left hip surgery, we provided analgesia with intraoperative fentanyl and lidocaine infusions, acetaminophen, a single-shot femoral nerve block, and rescue hydromorphone. One week after the first surgery, the patient underwent right hip surgery. This time he received an intraoperative ketamine infusion, acetaminophen and we placed an ultrasound guided erector spinae plane catheter at L4 level with a 0.125% bupivacaine infusion (0,3 mg/kg/h)

After the first surgery, the patient experienced severe postoperative pain after the resolution of a single-shot block, requiring high-dose opioids and management by the pain service. Following the second surgical stage and ESP block, hydromorphone rescue doses were not required and adequate postoperative pain management was achieved.. The patient was discharged six days after the second surgery.

In the presented case, the ESP block was a safe and effective option for postoperative pain management in patients with multiple comorbidities undergoing Klisic surgery

The Royal College Of Anaesthesia (RCOA) 2021 curriculum mandates Anaesthetists in Training (AIT) to master all PLAN A blocks by CCT. Regular practice and ultrasound workshops are pivotal for training in regional anaesthesia (RA). To enhance RA training accessibility, we propose initiating a mobile RA club focusing on PLAN A BLOCKS and sharing credible online RA resources. Our objective is to gauge awareness of PLAN A BLOCKS, preferred RA learning sources, and receptiveness to establishing local Sono clubs in Northwest hospitals.

A survey comprising 10 questions, including one open-ended query, was distributed to Northwest Anaesthetists, yielding 46 responses within 5 days.

Findings reveal over 70% familiarity with PLAN A BLOCKS, yet most possess limited experience with upper limb and truncal blocks. Reputable online sources are favoured for individual learning, although nearly 70% do not engage with any online RA platform. Notably, 32% lacked RA training in the past year, while almost all expressed interest in localized RA teaching during hospital rotations.

While progress in RA training and practice is evident in the region, opportunities for improvement persist. We have initiated the dissemination of coded reputable online resources, such as the Regional Anaesthesiology and Acute Pain Medicine YouTube channel, and plan to establish a mobile RA Club. This initiative will leverage advanced regional trainees' rotations to new hospitals with the guidance of Local/visiting consultants. A mandatory 3-month regional rotation may be necessary in the future to further enhance RA proficiency.

Peripheral nerve blocks are widely used for surgical anesthesia as well as for acute or chronic pain management.

The PNBs offer significant benefits over neuraxial or general anesthesia, as the latter may lead to respiratory and cardiovascular complications.

A 73-year-old male patient (ASA IV), presents with gangrene of his left arm and left arm amputation below the elbow is decided. From his medical history he suffered from lung cancer, had a cardiac pacemaker, single kidney, received medical treatment for arterial hypertension, dyslipidemia, hyperuricemia and atrial fibrillation. From his surgical history, he had undergone three surgical procedures on the afflicted arm with post - surgical admission to the ICU. His echocardiogram showed an Ejection Fraction of the left ventricle of 53% and a mitral valve stenosis. To ensure that the arm amputation could be performed without causing additional systemic harm and to avoid the need for post - surgical ICU admission, an axillary brachial plexus block was administered using 15 ml of 0.5% Ropivacaine. The patient remained hemodynamically stable throughout the perioperative period. After surgery, the patient stayed in the Post Anesthesia Care Unit for 30 minutes before being transferred to the Vascular Surgery Department, with no complications reported.

The PNBs are a valuable alternative as a method of surgical anesthesia as well as a method of perioperative analgesia in a multimodal analgesic plan, for high risk patients, in order to reduce perioperative mortality and morbidity.

The erector spinal plane (ESP) block, described by Fornero in 2016, has been studied and prescribed for thoracic surgical procedures. The lumbar ESP has been proposed as an alternative for interventions involving the lumbar plexus innervation. We present a case report of an aged fragile patient undergoing hip fracture surgery, using a lumbar ESP block as an anaesthetic strategy.

The hip innervation involves elements of the lumbar plexus (L2-L4) and sacral plexus (L5-S4). The anterior aspect of the joint receives a thick innervation from the femoral nerve, obturator nerve and accessory obturator nerve branches. Meanwhile, a bunch of sacral plexus contributes to the innervation of the posterior aspect of the joint, being the sciatic nerve the most important contributor.

The lumbar ESP block aims to interrupt all the femoral nerve branches. This novel approach implies a number of advantages, including the reduction of opioid usage, the reduction of nerve or vascular damage, the reduction of systemic repercussions and the reduction of hemorrhage complications, among others. Furthermore, this blockage provides effective postoperative pain control, a crucial aspect in complex patient. On the other hand, the possible disadvantages are the lack of evidence proving its efficacy, the proximity to deep organs and the large volume required to perform this blockage.

In this case report, we will present the successful usage of the lumbar ESP block in the anesthetic strategy, and discuss arguments for and against its use.

Fascioscapulohumeral muscular dystrophy (FSHD) predominantly affects muscles of the shoulder girdle, upper arm and face but can also affect the diaphragm resulting in restrictive lung disease. Loss of scapular muscle control limits range of shoulder movement and scapular winging may cause chronic pain. Scapulothoracic fusion aims to improve shoulder function and comfort but can be associated with significant acute postoperative pain. Pre-existing respiratory dysfunction is also exacerbated perioperatively by the application of a thoracic spica. We describe a perioperative analgesic strategy utilising regional analgesia, as an opiate sparing technique, in nine patients undergoing scapulothoracic fusion.

Electronic health records were retrospectively reviewed for nine patients who underwent scapulothoracic fusion between 2019 and 2023, after obtaining verbal consent. Data were collected on anaesthetic technique and post operative morphine requirements. Oral morphine equivalent daily dosing was calculated, according to faculty of pain medicine and BNF equivalence charts in recovery, at 24 hours and 24-48hours.

All nine patients received an interscalene brachial plexus block (ISNB) with perineural catheter insertion and erector spinae plane (ESP) block pre-surgical start and ESP interfascial catheter at the conclusion of surgery. Four of the nine patients were using opiates prior to surgery and postoperative opiate consumption is outlined in table 1.

Scapulothoracic fusion can be associated with significant acute postoperative pain. Preoperative ISNB and ESP blocks with post-operative ISNB perineural catheters and ESP catheters offer a useful opiate sparing analgesic adjunct in patients at high risk of postoperative pulmonary complications.

Subclavian Transcatheter Aortic Valve Implantation (TAVI) under sedation and peripheral nerve blocks is increasingly being adopted with better outcomes when compared to general anesthesia because of reduced hemodynamic support as well as reduced pulmonary complications. We present a case of a 68-year-old woman, ASA IV, with COPD GOLD D and severe aortic stenosis admitted for a subclavian TAVI. We aim to demonstrate that the realization of regional nerve blocks facilitates subclavian access and can be safely performed with effective anesthesia and minimal respiratory risk for the patients.

A single shot, ultrasound-guided, left interscalene brachial plexus (IBPB) and a superficial cervical plexus (SCPB) nerve blocks were performed using 0,375% ropivacaine (7ml for IBPB + 5ml for SCPB) in order to block the nerves that provide cutaneous innervation to the anterolateral neck and infraclavicular region. An infusion of dexmedetomidine at 1 mcg/kg/h was then induced, 10 minutes before the beginning of the procedure until the end.

The event was uneventful and effective anesthesia and post-op analgesia were achieved without respiratory nor hemodynamic intercurrences.

This case successfully enhances the advantages of regional anesthesia in patients with respiratory compromise. Although there is the risk of phrenic nerve palsy secondary to IBPB, the combination of low-dose and low-volume of local anesthetic minimizes the risk, along with a proper sedation that doesn’t cause respiratory depression.

At our institution, the responsibility for administration of local anaesthetic doses via peripheral nerve catheters is shared between pain specialist nurses and the on-call anaesthetist. However, due to factors such as workload it is not possible to administer every dose. We aimed to quantify the proportion of doses administered, and to identify deficiencies to guide interventions to improve this.

Over a 6-month period starting November 2023, data were collected regarding the catheters inserted, prescriptions, number of doses administered and missed, duration in-situ and documentation regarding missed doses. The number of potential doses was calculated based on the frequency of the prescription, and the duration left in-situ.

67 peripheral nerve catheters were inserted; 47 rectus sheath, 17 serratus anterior/erector spinae plane and 3 fascia iliaca. The median duration in-situ was 4 days (local hospital guidelines 3-5 days). Only 432 (47%) doses were administered out of 903 potential doses. Factors leading to missed doses included workload, handover omission and missing prescriptions.

Peripheral nerve catheters are currently not being optimally utilised for analgesia, whilst patients are being exposed to the risk of insertion complications. In the short term, we will implement multiple interventions with the aim of increasing the proportion of doses administered, such as improving handover and prompting prescriptions after insertion. Another solution being explored is using dedicated programmed intermittent bolus pumps, but these come with both training and financial implications. Local governance recognised the risk as described by our audit, and a process of procuring these pumps has been commenced.

Above-knee amputation (AKA) under regional anaesthesia alone can pose multiple challenges to anaesthetists [1]. For AKA, ultrasound-guided selective sciatic nerve, posterior femoral cutaneous nerve (PFCN), femoral, lateral femoral cutaneous, and obturator nerve blockade provide satisfactory anaesthesia.

A 52-year-old woman with ischemic heart disease, atrial fibrillation on therapeutic anticoagulation, chronic kidney disease stage 3, poorly controlled diabetes mellitus, anaemia, and heart failure (ejection fraction 25-30%) was scheduled for an urgent left AKA under regional anaesthesia block due to ascending infection. Considering the high risk, a suprainguinal fascia iliaca block with a perineural catheter was performed under ultrasound. Visualisation of the sciatic nerve and the PFCN was unsuccessful as the neurosonoanatomy was undetectable. The motor response using a nerve stimulator to the suspected sciatic nerve failed, too. 0.5% levobupivacaine 20ml was administered in the area of the suspected nerves using piriformis and other sonoanatomical landmarks. Amputation was carried out without additional analgesia or sedation.

Intraoperatively, the sciatic nerve was found to be distorted macroscopically due to liquefactive necrosis. Postoperatively in HDU, her pain control was satisfactory with perineural infusion.

The inability to identify the sciatic nerve due to liquefaction is a peculiar encounter in this patient. Still, it hints at an unusual cause for difficult peripheral nerve visualisation and stimulation. Due to the fact that the sciatic and PFCN lie closer when they exit the sciatic foramen under piriformis (2), a sufficient volume of local anaesthetic during sciatic nerve block may spread around and anaesthetise PFCN.

A 37 year old female with high BMI presented to the emergency department with a traumatic elbow dislocation following a fall whilst intoxicated with alcohol. Initial reduction attempts under sedation were unsuccessful. Due to concerns about potential neurological complications, the patient was listed for an urgent reduction of the elbow joint in trauma theatre. In theatre a supraclavicular nerve block was performed to provide analgesia and anaesthesia allowing for successful reduction of the elbow joint.

A supraclavicular block was performed under ultrasound guidance using a combination of 10ml 2% Lidocaine and 10ml 0.5% Bupivacaine with 1:200,00 adrenaline. A regional anaesthetic technique was chosen to avoid the risks of potential aspiration and difficult airway management.

Reduction of the elbow joint was performed successfully with excellent analgesia and muscle relaxation provided by a supraclavicular nerve block. Throughout the procedure the patient reported a positive experience with much improved analgesia and comfort.

This case underscores the efficacy of regional anaesthetic techniques in managing patients undergoing surgery on trauma operating lists. A supraclavicular nerve block provided excellent surgical conditions to allow for successful reduction of a dislocated elbow joint, whilst also avoiding the potential risks of aspiration and difficult airway management associated with alcohol intoxication and high BMI. The use of lidocaine and bupivacaine allowed for both rapid onset and adequate duration of regional blockade, contributing towards patient satisfaction. This approach should be considered a viable option for managing similar clinical scenarios, specifically for patients in whom a general anaesthetic may carry increased risk.

As the population ages, patients with multiple comorbidities and on antiplatelet and anticoagulant therapy increase, posing a challenge for high-risk surgical patients requiring urgent lower extremity surgery, where neuraxial block is the preferred anesthetic approach.

A 62-year-old man, ASA IV (type 2 diabetes, terminal-stage renal failure, peripheral arterial disease with bifemoral endovascular prosthesis, ischemic cardiomyopathy, requiring coronary artery bypass grafting) under dual antiplatelet therapy (Aspirin 100mg and Ticagrelor 160mg daily) was planned for urgent transfemoral amputation. To minimize the risks of general anesthesia and because neuraxial anesthesia was contraindicated due to dual antiplatelet therapy, the patient underwent ultrasound-guided femoral and subgluteal sciatic nerve blocks using 35ml of ropivacaine 0,5% and 20ml of lidocaine 1%. Sensory and motor blockades were assessed every 5 minutes until the desired block level was achieved. Propofol (80mg) and ketamine (50mg) were used in incremental dosages for patient comfort. Intraoperatively, the patient maintained hemodynamic stability, and surgery was uneventful. He was transferred to an intermediate care unit, being transferred to the vascular surgery ward after 2 days. Postoperative pain was managed with regional blocks, intravenous paracetamol 1g every 6 hours, and tramadol 100mg as rescue analgesia. He was discharged home after 14 days.

This case highlights the advantages of peripheral nerve block (PNB) in high-risk patients when neuraxial anesthesia is contraindicated. For above-knee amputation surgery, successful surgical anesthesia and improved postoperative outcomes are achieved using a combination of femoral and sciatic nerve blocks2. PNB provides hemodynamic stability, improved postoperative analgesia, and reduced morbidity and mortality rates.

Breast cancer is the most common type of cancer in women. The increase in average life expectancy leads to more comorbid and older women undergoing breast surgery. Usually, modified radical mastectomy is performed under general anesthesia. It is possible and reasonable to choose a less invasive approach in these patients such as peripheral nerve block techniques.

We present an 85 year-old woman, ASA IV, diagnosed with advanced invasive carcinoma of the right breast who underwent right radical mastectomy with lymph node dissection. The patient had several comorbidities such as pulmonary hypertension, respiratory failure under night BiPAP and long-term oxygen therapy, heart failure, ischemic cardiomyopathy, chronic kidney disease. Anticipating the high anesthetic risk the anesthesiology team decided to perform the procedure under regional anesthesia. The regional anesthesia performed was based on a belt and brace approach, blocking all the contribution to the right breast. Thus, it was planned a paravertebral block in 3 levels complemented with interectoral, pectoserratus, supraclavicular nerves and a pectointerfascial block. To maintain redundancy and safety a high thoracic epidural catheter was left in place. Due to technical difficulties performing a paravertebral approach in one of the levels a erector spinae plane block was performed as a rescue in T3-T4. All the blocks combined enabled a safe and painless surgery with a minimal sedation for patient’s comfort.

It is mandatory to suit the anesthetic technique to the patient. This case illustrates the possibility of performing a major surgery avoiding general anesthesia for the patient's best outcome and safety.

Shoulder surgeries by arthroscopy or open methods have increased in recently. Regional Anesthesia is an excellent supplement to GA as well as can be used as the sole anesthetic technic in high-risk patients.

We present the case of an 81-year-old female, known case of CAD, HTN, DM and Rheumatoid arthritis who was posted for shoulder debridement. She had a hospital re-admission after 2 days of hospital stay for 2 weeks due to septic shock (left shoulder infected wound) and AKI on CKD, requiring dialysis. She was re-admitted to MICU as she developed shortness of breath and generalized edema. CXR showed congestion and bilateral pleural effusion. PE was ruled out by CT. She was hypotensive requiring noradrenaline infusion. The diagnosis was Left shoulder draining sinus (septic arthritis) and she was posted for debridement. Owing to multiple comorbidities, it was decided to carry out the procedure under regional anesthesia. She was shifted to OR with Noradrenalne infusion which was continued intraoperatively. She received a left Interscalene block (15ml 0.5% Levobupivacaine), superficial cervical plexus block (5ml 0.33% Levobupivacaine) & Supraclavicular block (5ml 0.33% Levobupivacaine). She underwent Debridement and wash of Left shoulder and sinus excision.

She tolerated the procedure, without any sedation. Her clinical condition dramatically improved following the surgery, and she was weaned-off Noradrenaline the next day. She was transferred to the medical floor on the second post-operative day.

Peripheral Nerve Blocks can be used as sole anesthetic technics for shoulder surgeries in high-risk patients in whom general anesthesia can be challenging.

We describe Surgery specific regional anaesthesia(SSpecRA), as the term/concept in which according to the diagnosis and planned surgery, a regional anaesthetic technique is planned for surgical anaesthesia comforting the patient and reducing the risk associated with blocking unwanted structures, on one hand reducing complications and on the other hand preventing conversion to general anesthesia in high risk patients(Table 2). The nerves to be blocked for a particular surgery should be analyzed and tailored to be done exclusively under regional anesthesia.We analysed for clavicle fixation[Table 1].

A 51y old male massively obese(BMI-52.14kg/m2) with OSA was posted for open reduction and internal fixation of the closed/displaced fracture of left clavicle. Ultrasound guided left superior and middle trunk brachial plexus block(SMTBPB) with left superficial cervical plexus block(SCPB) was administered. 5 ml of LA mixture given around superior trunk and 5ml around middle trunk just before its division into anterior and posterior. Left SCPB administered with 10ml of LA mixture. LA mixture is prepared by 10ml of 2% lignocaine with adrenaline(1: 200,000) and 10ml of 0.5%bupivacaine.Multiple measures taken to prevent phrenic nerve blockade.

Surgery was done successfully under regional anesthesia without need for conversion to GA. Intra operatively patient was comfortable. He did not have symptomatic dyspnoea or desaturation(phrenic nerve), Horner’s syndrome(sympathetic chain) or hoarseness of voice (recurrent laryngeal palsy).

Surgery specific regional anesthesia for clavicle surgery, spares phrenic nerve ensuring clavicle surgery only under regional anesthesia, in high risk patients(massively obese), who otherwise may not tolerate diaphragmatic palsy secondary to regional anaesthesia

Osteogenesis imperfecta (OI), is a rare autosomal dominant inherited disorder caused by an abnormality in the production of type I collagen, characterised by fragility and bone deformities with multiple fractures caused by minimal trauma. These clinical manifestations not only have an impact on anaesthetic management (risk of intubation and ventilation), but are also linked to surgery to correct the deformities, in particular osteotomies, which are a major source of post-operative pain.the interdisciplinary approach is the cornerstone of the treatment, which has two essential components: Anaesthesia and overall multimodal analgesia as part of early rehabilitation

We will discuss our experience of the intraoperative analgesic management of 25 IO with femoral shaft fractures, undertaken in the operating theatre under GA. Intraoperative analgesia was provided by : Ketamine 0.5mg/Kg and dexamethasone 4mg at induction to prevent postoperative hyperalgesia Paracetamol IV15mg/Kg 30 min before the end of the operation. Musculocutaneous and pericatricial infiltrations (bupivacaine) at the end of the operation. Post-operative NSAIDs and paracetamol every 6 h. Pain assessment using a numerical scale after patients were fully awake and then at H2-H4-H6-H8

Significant reduction in post-operative pain without morphine consumption for the duration of the stay

the anaesthetic and analgesic approach to OI are specific , Loco-regional analgesia is evolving towards more selective targeted techniques. For optimised multimodal management, echo-guided femoral block cannot be performed (plaster cast applied at the end of the operation), neurostimulation is outlawed (risk of fracture); infiltration remains a simple, virtually risk-free alternative. The benefit/risk ratio is particularly favourable.

The utilisation of peripheral nerve blocks (PNBs) and regional anaesthesia (RA) is increasingly recognised. PNBs offer a non-invasive option for co-morbid patients, associated with less postoperative pain and less opiate-induced side effects, resulting in quicker discharge. The Royal College of Anaesthetists (RCOA) updated the curriculum in 2021 recognising the importance of RA in training. We developed a teaching program aiming to improve confidence, familiarity with sonoanatomy and develop practical ultrasound scanning skills needed for the seven Plan A blocks.

A teaching program was developed based on the seven Plan A blocks. Trainees were allocated one session per month for teaching. Funding was secured for two Bluetooth ultrasound scanners, allowing independent practice and development. Teaching content includes appropriate use of blocks, demonstration of surface anatomy and sonoanatomy. Each attendee has the opportunity to practice scanning. Feedback was sought using Likert scales and free text.

Feedback has been received on three sessions. • 100% of respondents found teaching useful. • 70% “strongly agreed” their confidence improved. • 30% “agreed” their confidence improved. • 100% of respondents found individual practice scanning beneficial to learning. Free text analysis highlighted improved confidence levels, relevance to training and clinical practice. Some preferred more assessment post teaching.

Developing a teaching program dedicated to the Plan A blocks has proven valuable. Trainees found the sessions beneficial to learning and confidence improved globally. Access to ultrasound allowed greater freedom to develop scanning skills. Ongoing sessions and feedback will allow further assessment of the impact of this project on training.

The PENG block is an effective and safe regional analgesic technique for patients with hip fracture. It is performed prior to surgery and covers the innervation of the anterior aspect of the hip joint, where much of the pain originates in this type of surgery. Although most nociceptive receptors are located in the anterior capsule, we should not ignore nociceptive stimulation in the posterior capsule. To address this, it is suggested to combine the PENG block with a preoperative intracapsular block.

We performed a PENG block by administering 15 mL of 0.375% levobupivacaine to the bony edge of the ileum plus injection of 5 mL of the same local anesthetic at equal concentration into the hip joint capsule in two patients with the follow characteristics: - 89 years old male with basicervical left hip fracture scheduled for percutaneous surgery with PFNA nail. - 77-year-old woman with pertrochanteric hip fracture scheduled for percutaneous Gamma nail surgery.

Both of the patients were mobilized without any pain, achieving comfort while mobilization and positioning, as well as better perioperative pain control.

Intracapsular block with intra-articular injection of 5 mL of local anesthetic covers the posterior nociceptive capsular fibers, guaranteeing total analgesia of the hip joint during perioperative mobilization. The PENG block complemented by the intracapsular block in the preoperative period allows for painless mobilization and positioning of the patient, and is useful if there is a need to sit down if neuraxial anesthesia is difficult to administer in the lateral decubitus position.

Analgesia for cardiac median sternotomy using pecto-intercostal fascial block (PIFB) after cardiac surgery has long been described. The ultrasound-guided PIFB can cover the anterior branches of intercostal nerves from T2 to T6 and reduce postoperative pain scores and opioid requirements in cardiac surgical patients.

A 72-year-old man, ASA III, obese with COPD, was admitted to the ICU after a car crash with thoracic trauma (2nd to 5th anterior right ribs). Despite the introduction of multimodal intravenous analgesia (Paracetamol 1g 6/6h, Metamizol 1g 8/8h, Tramadol 100mg 8/8h, Morphine SOS), the pain was uncontrolled. Simultaneously, he developed a functional ileus which further compromised his respiratory function, requiring ventilatory support with a high-flow nasal cannula. The patient reported intense pain (VAS 10), to the anterior right side of the sternum, particularly with cough and deep inspiration. We performed an ultrasound-guided, single-shot, right PIFB, with 20mL of ropivacaine 0,2% without complications.

Twenty minutes after the PIFB, the patient reported a substantial improvement in thoracic pain (VAS 2/3), that lasted for 12h. For the duration of the block, the analgesic requirements decreased, and opioids were no longer needed. Laxatives were given and bowel function improved with a reduction of abdominal volume. Subsequently, pulmonary function improved, and ventilatory support decreased. He still required a nasal cannula but oxygen flow was reduced.

The use of PIFB is an effective alternative analgesic approach for rib fracture of the anterior thorax, as it provides long-lasting analgesia, reduces opioid requirements, and its side effects, and improves respiratory function.

The suprainguinal Fascia Iliaca Compartment Block (S-FICB) is crucial for managing pain in hip fracture patients, necessitating precise skills and knowledge. Educational workshops have proven effective in enhancing clinical skills and confidence among medical professionals. This study at Macclesfield District General Hospital (DGH) assesses the impact of a targeted workshop on anaesthetic doctors' proficiency in S-FICB. Aims: 1.To assess the effectiveness of a workshop on S-FICB in improving the confidence and knowledge of anaesthetic doctors. 2.To gather feedback on the educational value of the workshop and identify areas for future improvement.

Twelve anaesthetic doctors attended the workshop and completed pre- and post-surveys. Surveys, validated by two consultant anaesthetists, assessed confidence and knowledge of S-FICB. The workshop included a PowerPoint presentation, a live demonstration on a patient, and a post-survey. Data were analyzed using descriptive statistics and paired t-tests.

Participants:12 anesthetists: 2 consultants, 7 specialty doctors, 3 core trainees Pre-Workshop Scores Confidence: Mean 2.33 ± 1.07 Knowledge: Mean 3.75 ± 1.25 Post-Workshop Scores Confidence: Mean 3.75 ± 0.75, p < .001 Knowledge: Mean 4.16 ± 1.16, not significant Feedback High educational value (Mean 5) 91.7% recommended regular workshops 33.3% suggested hands-on scanning stations

The workshop significantly increased the confidence of anaesthetic doctors in performing S-FICB, as evidenced by a statistically significant improvement in confidence scores. Although knowledge scores improved slightly, the change was not statistically significant. The high mean score for educational value and positive feedback suggest that participants found the workshop highly beneficial.

Patients with critical limb ischemia represent a significant anesthetic challenge due to multiple severe comorbidities, established chronic pain, and use of systemic anticoagulation. These patients often require multiple high-pain procedures and prolonged hospital stays, frequently culminating in lower limb amputation. In this complex clinical setting, peripheral regional anesthesia emerges as a crucial tool, allowing for better pain control, reduced opioid consumption, lower incidence of phantom limb pain, as well as reduced respiratory complications and sepsis.

This case report details the anesthetic management of an 85-year-old patient presenting for transfemoral amputation. The patient had CKD-V under renal replacement therapy, ischemic heart disease with reduced ejection fraction of 23%, COPD, dyslipidemia, type II diabetes, a failed bypass graft under high dose opioid requirements and systemic anticoagulation with LMWH.

The patient's enoxaparin was suspended 24 hours prior to surgery. A femoral nerve block, sciatic nerve block via transgluteal approach, obturator nerve block via a subpectineal approach, and lateral femoral cutaneous nerve block were successfully performed, and sciatic and femoral catheters were placed. The transfemoral amputation was performed without the need for additional sedoanalgesia. There were no anesthetic or surgical complications. During the procedure, 1 unit of red blood cells and 1 gram of tranexamic acid were administered. The patient remained in the PACU for 48 hours for surveillance with nurse-controlled analgesia, achieving good pain control.

Peripheral regional anesthesia provided effective anesthesia and analgesia, and facilitated a complication-free transfemoral amputation in a high-risk patient, demonstrating its effectiveness as an anesthetic approach in complex cases.

Introduction Regional anesthesia provides a safe and efficient alternative anesthetic management modality in cases with high aerosol transmission risks and post operative pulmonary complications. This case describes the anesthetic management of emergency left thumb amputation on a patient with active lung tuberculosis and spontaneous pneumothorax.

Case illustration A 26-year-old woman presented to the emergency room with increasing dyspnea and yellowish-white and bloody discharge from a huge mass on her left thumb. Patient was diagnosed with spontaneous pneumothorax, lung tuberculosis diagnosed 6 days prior, and infection of primary bone tumor on her left thumb. Placement of chest tube was followed by amputation of left thumb using a mid-arm tourniquet. An ultrasound-guided axillary brachial plexus and intercostobrachial block was performed under sedation with targeted controlled infusion (TCI) Propofol.

Discussion General anesthesia for elective surgeries in patients with active lung tuberculosis is recommended to be postponed until 2 weeks post anti-tuberculosis treatment. This case necessitated emergency amputation for source control and peripheral nerve block was effective in preventing aerosol contamination without requiring airway instrumentation for general anesthesia nor positive pressure ventilation that could have increased the patient’s risk for recurrent pneumothorax. In addition to conventional axillary brachial plexus block, intercostobrachial nerve block was performed for adequate anesthesia because of the tourniquet use.

Conclusion Regional anesthesia is a reliable modality for patients and healthcare personnel in cases with high risks of infectious aerosol transmission. The additional intercostbrachialis block enabled anesthesia coverage of the medial upper arm due tourniquet use.

Thoracic sympathectomy (TS) stands as a primary treatment for localized hyperhidrosis. At our institution, TS is performed under general anesthesia with a systemic multimodal analgesic regimen on an outpatient basis. However, the procedure can lead to moderate postoperative pain due to trocar insertion into intercostal spaces, carbon dioxide insufflation, and manipulation of the parietal pleura, often necessitating escalated opioid doses with associated adverse effects. This report details two cases of TS conducted under general anesthesia, supplemented with bilateral ultrasound-guided serratus anterior plane block (SAPB).

Two 20-year-old female patients underwent TS under general anesthesia. Following informed consent, bilateral ultrasound-guided SAPB was administered using 20 mL of 0.5% ropivacaine. Intraoperative intravenous analgesia included magnesium sulfate (2 g), acetaminophen (1 g), metamizol (2 g), ketorolac (30 mg), ketamine (20 mg), and dexamethasone (8 mg). Both surgeries proceeded without intraoperative pain, with Patient A reporting a postoperative pain score of 2/10 and Patient B reporting 4/10, managed with a single 2 mg dose of intravenous morphine. At discharge and during the 24-hour follow-up, both patients reported pain scores of 0/10, maintained with oral acetaminophen and celecoxib, with no reported side effects.

SAPB proved its efficacy as a component of multimodal analgesia for TS, reducing opioid dose throughout the perioperative period.

Effective multimodal analgesia is crucial for successful ambulatory surgery. SAPB, offering substantial anterolateral chest wall analgesia, presents as a promising option for ambulatory procedures, given its minimally invasive nature and lower complication rates. Further research is needed to substantiate these findings.

Traditionally, thoracic epidural analgesia (TEA) has been considered the gold standard for managing postoperative pain following laparotomy. However, technical challenges and the chronic use of anticoagulants have led anesthesiologists to seek alternative approaches. Ultrasound-guided Erector Spinae Plane Block (ESPB) has emerged as an interfascial plane block offering extensive somatic and visceral abdominal analgesia, demonstrating comparable efficacy to TEA at rest.

Two 54-year-old men, graded ASA-PS III, underwent elective Aorto-Bifemoral Bypass (ABFB). Case one had a history of grade III ischemic cardiomyopathy, while case two presented with moderate obstructive ventilatory defect. Both patients had severe peripheral artery disease. Bilateral ultrasound-guided ESPB was performed using 0.375% ropivacaine, with a total volume of 30 mL for case one and 60 mL for case two, tailored to their anthropometric features. Total intravenous anesthesia was induced, supplemented with intravenous acetaminophen (1g), ketorolac (30mg), and tramadol (100mg). Pain scores were assessed using numerical rating scales (NRS) at rest and during movement. A fixed intravenous analgesia protocol was established, comprising acetaminophen (1g) every 8 hours, metamizol (2g) every 12 hours, and tramadol (100mg) every 8 hours.

During the first five postoperative days, no pain scores greater than 3, need for rescue analgesia, or side effects were reported.

ESPB, as part of multimodal analgesia, provided optimal pain relief. Studies have highlighted its ability to provide extensive abdominal analgesia, making it a promising alternative to TEA for ABFB. Classified as a superficial block, ESPB presents lower risk to anticoagulated patients than TEA. Further investigation is required for validation.

Regional anesthesia offers significant advantages in managing patients with severe cardiovascular and respiratory comorbidities. However, in patients with hematological disorders, the bleeding risk can be considerable and overcome potential benefits. Balancing the pros and cons is crucial, yet regional anesthesia may still be the best option despite high intrinsic bleeding risks.

A 68-year-old male with lymphoma, presented with pancytopenia (40.000 platelets) and deep cervical adenopathies. His personal history included atrial fibrillation under rivaroxaban, ischemic heart disease with reduced ejection fraction under , and advanced COPD (basal oxygen saturation of 87%, and reliance on long-term domiciliary oxygen therapy). Excisional biopsy was needed to determine the appropriate chemotherapy regimen. An intermediate cervical plexus block was chosen as the anesthetic technique.

After multidisciplinary discussion with the immunohemotherapy service and surgical team, oral anticoagulant was interrupted for 48h. Pre-transfusion blood typing was conducted, a pool of platelets was prepared for potential uncontrolled bleeding, basal ROTEM analysis was performed, and 1g of tranexamic acid was administred. An intermediate cervical plexus block was performed, providing effective anesthesia without the need for additional sedation, while maintaining spontaneous ventilation and hemodynamic stability. Surgery was uneventful.

Despite the high bleeding risk, regional anesthesia was chosen due to the patient's significant pulmonary and cardiovascular comorbidities. This approach was deemed acceptable as it associated with reduced risk of postoperative intubation or major cardiovascular events in predisposed patients. This case underscores the importance of individualized anesthetic strategies in patients with complex medical histories.

Peripheral nerve blocks can be a valuable option for managing anesthesia and pain in patients with complicated distal leg fractures in the setting of polytrauma. Performing bilateral peripheral nerve blocks in an anorexic patient undergoing lower leg surgery may present some challenges. The patient's overall health status has to be carefully assessed, including any complications related to anorexia nervosa, such as electrolyte imbalances, cardiac issues, or compromised organ function. Sacral plexus injuries are relatively uncommon and can occur due to trauma, such as pelvic fractures.

28 years old polytraumatised female patient, BMI 13.7, was scheduled for a right lower leg fracture and left calcaneus surgery. The osteosynthesis of the tibia and fibula was performed in the popliteal with a saphenous nerve block and was followed by calcaneus surgery in the ankle block. The total amount of local anesthetic applied was higher than proposed for the weight, ankle block being performed 4 hours after the popliteal with saphenous block. The total amount of 0.5 % levobupivacain for the procedure was 200 mg. The duration of surgery was 7.5 hours, the estimated blood loss was 900 ml, and the patient was sedated with target controlled infusion of propofol.

Peripheral nerve blocks decreased the necessity for postoperative opioids. Electromyoneurography conducted two weeks after the surgery showed no variance from the preoperative findings.

The decision to perform bilateral nerve blocks should be made on a case-by-case basis, considering the risks and benefits for the individual patient.

We describe Surgery Specific Regional Anaesthesia(SSpecRA), as the term/concept in which according to the diagnosis and planned surgery, a regional anaesthetic technique is planned for surgical anaesthesia comforting the patient and reducing the risk associated with blocking unwanted structures, on one hand reducing complications and on the other hand preventing conversion to general anaesthesia in high risk patients. The nerves to be blocked for a particular surgery should be analysed and tailored for surgery to be done exclusively under regional anaesthesia with respect to the steps involved in the surgery, nerve supply to the skin, bony, capsular, muscular components and usage of tourniquet. Position during the surgery and discomfort from other injuries also to be considered.

A 60y old male with post traumatic, un-displaced Odontoid(C2) fracture without any neurological deficit, was posted for Closed Reduction Intramedullary Nailing of Tibia under tourniquet. Under USG guidance Right Femoral(25ml of LA mixture), Sciatic(30ml of LA mixture)was administered. LA mixture- 22.5ml of 2%Lignocaine with Adrenaline(5mcg/ml), 22.5ml of 0.5%Bupivacaine, 5ml of Sodabicarbonate7.5%, 3ml of Normal saline and 2ml of 8mg Dexamethasone. USG Obturator Nerve block(anterior branch(7ml) and posterior branch(3ml) of 0.2% Ropivacaine) was blocked for tourniquet at thigh. Safe Local Anaesthetic dosage, volume and concentration for surgical anaesthesia was considered.

Intraoperatively patient was comfortable and surgery was uneventful without conversion to general anaesthesia. Total duration of anaesthesia analgesia was around 7h.

USG guided Femoral, Sciatic and Obturator Nerve block can be considered as a sole Surgery Specific Regional Anaesthesia(SSpecRA) for intramedullary tibial nailing under tourniquet.

Local anesthetic systemic toxicity (LAST) is the most severe complication following local anesthetic (LA) administration. In orthopedic surgery, peripheral nerve blocks with LA have become increasingly popular due to its analgesic potential, thus making LAST more likely to occur in an orthopedic or trauma related clinical setting. Clinically, neurological presentation is the most common, but up to one-fifth of the reported cases present with isolated cardiovascular disturbance.

A 51-year-old woman, 60kg, with personal history of chronic hepatic disease and opioid dependency, underwent osteosynthesis of the fourth metacarpal. Ultrasound guided axillary approach to brachial plexus blockade was performed using 20ml of 0,5% ropivacaine (100mg). The LA was administrated fractionally and intravascular position was excluded by frequent aspiration. 5 minutes after LA administration, the patient related metallic taste, sialorrhea and an altered mental state – Glasgow Coma Scale 13. There was no cardiovascular alteration. LAST was rapidly assumed. General anesthesia was induced due to the altered mental status and LAST protocol was activated: administration of an 80ml bolus of lipidic emulsion 20%, 1000ml/h infusion during the first 10 minutes and 20 ml/h for 2hours. Anesthetic emergency was uneventful, with both motor and sensitive block of upper limb confirmed. The patient recovered previous mental status and remained 6 hours in Post Anaesthetic Care Unit continuously monitored without symptoms recurrence.

LAST incidence has been decreasing mainly due to proper safety measures and advances in technique, thus making education and simulation crucial for speedy diagnosis and adequate treatment to assure a positive outcome.

Horner’s syndrome (HS) is a known complication of interscalene brachial plexus block (IBPB), occurring when the local anesthetic spreads to the sympathetic chain near the brachial plexus (specifically the stellate ganglion). Patients may typically exhibit the classic HS triad (ptosis, miosis, and facial anhidrosis) shortly after surgery, often followed by spontaneous recovery. We present a case of a 68-year-old woman, ASA-III, with a traumatic left rotator cuff tear scheduled for ambulatory arthroscopic repair surgery.

An ultrasound-guided IBPB was performed using 20mL of 0.375% ropivacaine, followed by general anesthesia. The procedure was performed in a beach-chair position, lasted 111 minutes, and was uneventful. In the postanesthesia care unit, the patient was hemodynamically stable, pain-free and without HS symptoms and was transferred to the ambulatory ward for further vigilance.

About five hours after surgery, the patient reported blurred vision and ptosis in the left eye, with no other neurological signs, clearly suggesting HS. Twenty-nine hours after surgery, Horner's symptoms slightly improved, no residual motor block of the arm was registered and the patient was discharged with a follow-up scheduled for two weeks later. Persistent blurred vision and left eyelid ptosis were noted and an ophthalmological consultation documented slight anisocoria and left palpebral ptosis. A cerebral CT scan showed no abnormalities. Two months after surgery, HS spontaneously resolved.

This case aims to illustrate a prolonged HS after an ultrasound-guided IBBP. Anesthesiologists should remain vigilant, reassure patients, and conduct additional evaluations until full recovery.

Usage of the left internal mammary artery for coronary artery bypass grafting to the LAD is the gold standard due to better long term survival. We aimed to show the effects of anterior chest wall blocks on LIMA blood flow.

The study included 135 patients was started after the approval of Van Yuzuncu Yil University Clinical Research Ethics Committee. ASA II-III cases with at least one LAD graft were randomized to PECS, SAP and control groups. After standard anesthesia induction while anterior chest wall blocks were not applied to the control group, 15cc bupivacaine was applied to the PECS I area and 15cc bupivacaine to the PECS II area in Group PECS, and 30cc bupivacaine was applied to the appropriate area in Group SAP. LIMA harvested, LIMA pedicle was sprayed with diluted papaverine. LIMA free flow was estimated by allowing the open distal end of LIMA to freely bleed into a small bowl for 20 s, measuring the amount of collected blood and the flow per minute was calculated accordingly. Results were evaluated with SPSS 27.0 program.

Demographic data were not statistically different between the groups (p>0.05) (Table 1). LIMA blood flow was significantly higher in the SAP and PECS groups (p<0.05) (Fig 1). The highest intubation-extubation interval was found in the C group (p<0.05) (Fig 2).

The results may be interpreted as an increase in LIMA graft quality, positive effects on patient survival and quality of life, and decreased cost to the patient and the healthcare system.

In 2023 some # NOF patients who are elderly(>80) were too hypotensive and drowsy for Physiotherapy postoperatively.Side effects due to CNB, include that of sympathetic blockade, such as hypotension in approximately 30% less than baseline or with systolic blood pressure <90mmhg, . Decision was taken to audit the impact of postoperative haemoglobin on mobilisation postop and blood pressure for elderly #NOF patients.

Retrospective data analysis 2 groups of patients undergoing #NOF:.2 Standard anaesthesia techniques - Spinal anaesthesia with peripheral nerve blocks ( PENG+LFCN/SIFI)-( spinal anaesthesia , 20 mls 0.25% Levobupivacaine usg guided block). Asymptomatic group(control) vs Symptomatic group- symptoms were BP <90 mm hg and inability to mobilise due to drowsiness/agitation. Demographics - All ASA 3&4 patients , >80 Years Data Collected-Pre-, Intra- and postoperative BP hourly. 22 patients identified as too hypotensive or drowsy for Physio, 18 asymptomatic #NOF patients.

➢ Similar Anaesthetic techniques used , ASA 3 & 4 patients in both groups with PNB ➢ More significant HB drop in the hypotensive group Unpaired t test results – HB comparison for the hypotensive and control group The two-tailed P value = 0.2771

Introduction of HB check for every patient in Recovery –Haemocue or Venous bloog gas. ➢ Introduction of a Haemocue Sticker to check ➢ Recommend same day FBC HB check for low results on Haemocue and high-risk patients….. 2-3 hours post-op. Communicate with T&O ward team. ➢Avoid usage of intrathecal opiates in spinals for #NOF patients ➢Advise following the Prospect Guidelines for tailored postoperative analgesia

Transurethral resection of bladder tumor (TUR-BT) is the gold standard for the diagnosis and initial treatment of this type of cancer. Bladder perforation is a major complication associated with both surgery and anesthesia. Obturator nerve (ON) block minimizing the risk of ON reflex (ONR) has been proposed as an effective strategy to prevent this catastrophic complication.

An 85 year -old male, ASA III, patient, presented in our Anesthesiology Department for TUR-BT. Preoperative bladder ultrasound revealed a tumor affecting both lateral walls. After explaining the procedure to the patient and having obtained informed consent, the high frequency ultrasound probe was placed, under sterile conditions, at the medial aspect of the right femoral crease and a 50 mm- long insulated needle was inserted in plane and guided in the fascial plane between the pectineus and adductor brevis and the fascial plane between adductor brevis and adductor magnus muscles. Local anesthetic solution was incrementally injected (15 ml mixture ropivacaine 0,5% with lignocaine 0,1%). The same procedure was repeated to block the branches of the left ON. Twenty minutes after bilateral block, 3 ml hyperbaric bupivacaine 0,5% and 10mcg fentanyl were injected intrathecally.

During the 50 -minute procedure no obturator jerk was observed and no other adverse effect was recorded.

Spinal anesthesia (SA) combined with ONB has been shown to be superior to SA alone, in reducing the incidence of adductor spasm and associated complications. Our case provides additional evidence encouraging the application of ONB in patients presenting for TUR-BT.

Currently three types of regional nerve blocks are in use to provide analgesia to patients with hip fractures; the Fascia-Iliaca Compartment Block (FICB), Femoral Nerve Block (FNB) and Pericapsular Nerve Group Block (PENG). It is unclear which of these provides the best analgesia and the lowest number of complications. This systematic review aims to evaluate the literature concerning the efficacy and safety of pre-operatively placed PENG block compared to FICB and FNB for hip fractures.

The PRISMA statement guidelines were used and a systematic search of MEDLINE (via Ovid), Embase, Web of Science and Google Scholar was performed until April 8th 2024.

118 studies were identified, and after review 18 studies were included. Significant heterogeneity in outcome measures was present. Patients receiving PENG block reported better pain score outcomes (12 out of 17 studies), better patient satisfaction (5 out of 7 studies), better movement or quadriceps strength (4 out of 5 studies), less additional opioid use (5 out of 10 studies) and improved EOSP (4 out of 7 studies). None of the studies found FNB or FICB be favourable on these outcomes. No significant differences were found between blocks for (serious) adverse events.

PENG block is a promising technique to provide analgesia to patients with a hip fracture. However, there is significant heterogeneity in both endpoints used and in outcomes of the various studies that compared PENG with FM or FICB blocks. Larger randomized controlled trials with patient-centred outcomes are required to definitively establish which nerve block is most effective.

Axillary brachial plexus block is an effective and safe method of anesthesia for forearm, wrist and hand surgeries. The addition of adjuvant drugs, such as ketamine, to peripheral nerve blocks prolongs and enhances their effect. The present study aimed at investigating the role of ketamine administration route in the onset time and duration of nerve block and at examining the impact of ketamine supplementation on postoperative analgesia and incidence of rebound pain after block resolution.

Eighty-one patients were included in this single-blind comparative study, divided into Group 1 (Control), Group 2 (IV) and Group 3 (Regional). All three groups received 30 ml of ropivacaine 0.5% regionally. In addition, Group 2 received a bolus dose of 30 mg ketamine intravenously, while Group 3 received 30 mg ketamine regionally. Time of establishment of sensory and motor blockade, the degree of blockade, duration of analgesia, patients' postoperative pain intensity (in Numerical Rating Scale-NRS), dose of opioid administered postoperatively and possible side effects of the blockade were recorded.

Both regional and intravenous ketamine supplementation of ropivacaine were associated with faster onset of blockade (p<0.0005) and lower rebound pain NRS scores at 16, 20 and 24 hours postoperatively than local anesthetic alone (p=0.049, 0.009 and 0.006, respectively.) No significant difference was observed in motor block scores and postoperative opioid intake among the three groups.

Intravenous and regional addition of ketamine to ropivacaine solution for axillary branchial plexus block reduced the onset time of sensory and motor block and improved postoperative analgesia by attenuating rebound pain.

Hip surgery typically utilizes general or spinal anesthesia as the main anesthetic technique. We hereby describe a patient who underwent hip endoprosthesis in which an anterior (A-PENG) and posterior (PONG) ultrasound guided pericapsular infiltration has been performed along with additional local anesthetic (LA) skin infiltration, avoiding both general and spinal anesthesia.

A 77-year-old ASA 2 patient with left hip fracture was scheduled for endoprosthesis surgery by posterolateral approach (PLA). Informed consent is obtained. After premedication with 100μg fentanyl and 3mg midazolam, in supine position, the A-PENG was performed: the probe was placed anteriorly along the axis of the femur neck, then 10ml 2% mepivacaine+adrenaline +10ml 0,75%ropivacaine were injected in the pericapsular plane (FIG 1). After turning the patient on the counterlateral side, the PONG was performed: the probe was placed transversely between the greater trochanter and the ischial tuberosity, targeting the plane below the quadratus femoris. Here, 10ml of anesthetic mixture were injected. The trochanteric insertion of the piriformis, the skin and subcutaneous tissue infiltration has been performed with the remaining 10ml of anesthetic mixture diluted with 10ml of saline. Sedation with propofol TCI was carried out throughout surgery.

Surgery was performed uneventfully. No pain was recorded up to 24h after surgery. Standard analgesic regimen consisted of paracetamol 3g/day+ketorolac 90mg/day. The addition of adrenaline reduced intraoperative blood losses.

This approach allowed the avoidance of both general and spinal anesthesia, assuring adequate pain control without motor impairment.

A 65-year-old female was listed for bilateral unicompartmental knee replacement (medial compartment) in one sitting as a robotic assisted surgery. Her background medical history included hypertension, high BMI and osteo-arthritis. Patient was consented for spinal anaesthesia and bilateral adductor canal nerve block. A separate consent form for medical illustration and publication was explained, requested and signed by the patient.

Upon arrival to the anaesthetic room, bilateral adductor canal blocks were performed under ultrasound (USG) guidance in accordance with AAGBI full monitoring guidelines for peripheral nerve blocks using 12 millilitres of ropivacaine for either side. Given the nature of bilateral surgery and possible extended duration, a combined spinal epidural (CSE) was sited and the patient was given 2.8mls of bupivacaine intrathecally. Surgery was successfully completed by topping up the epidural catheter using to extend the neuraxial blockade without any untoward incidents and the epidural catheter was removed before transferring to the recovery. Post-operative pain was assessed using pain scores during the immediate post-op, 8hours and 14 hours following surgery. Regular analgesia including paracetamol and codeine were prescribed with morphine available as needed for breakthrough pain.

Patient was pain free in recovery and pain scores at 8 and 14 hours (at rest and with movement) were 0. She was discharged 16 hours after surgery.

Adductor canal block can be an effective means for postoperative analgesia for unicompartmental knee replacements. The presence of vastoadductor membrane (VAM) should be considered for superior analgesia.

Relapsing polychondritis is a rare, chronic autoimmune disorder, characterized by inflammation of cartilaginous structures. This abstract describes the use of a supraclavicular block in a patient with polychondritis undergoing upper limb surgery, highlighting its efficacy and benefits over general anesthesia.

A 66-year-old female with a known history of relapsing polychondritis was presented for urgent surgery due to a multifragment humerus fracture. She had a history of nose and ear cartillage inflamation and prior surgery was examined by an otorhinolaryngologist who ruled out acute inflammation of the larynx and recommended avoiding general anesthesia. A decision was made to perform a supraclavicular block to provide surgical anesthesia. Under ultrasound guidance, a supraclavicular block was performed (20 ml mixture of 0.5% levobupivacaine with 2% lidocaine) , achieving successful sensory and motor blockade of the upper extremity. The patient's vital signs were continuously monitored, sedation with small dose TCI propofol (1 mcg/ml) was administered to ensure comfort without compromising respiratory function.

The supraclavicular block provided effective anesthesia for the duration of the surgical procedure, which lasted 2 hours. The patient remained hemodynamically stable with no respiratory complications. Postoperatively, the patient reported excellent pain control and no adverse effects related to the block.

Supraclavicular block is effective anesthetic option for patients with relapsing polychondritis undergoing upper limb surgery. It avoids the risks associated with airway manipulation and general anesthesia. This case supports the consideration of regional anesthesia techniques in managing patients with complex autoimmune disorders, emphasizing the importance of individualized anesthetic planning.

Pulmonary Langerhans cell histiocytosis (PLCH) is a diffuse lung disease caused by accumulation of large numbers of CD1a+ cells in bronchiolocentric granulomas. It usually occurs in young adult smokers and may affect bronchiolar, interstitial and pulmonary vascular compartments. One-lung ventilation during video-assisted thoracoscopy (VATS) has been associated with acute lung injury which can lead to damage to the lung parenchyma. Evidence suggests that VATS performed under regional anesthesia may improve patient outcomes when compared to general anesthesia.

Case report.

A 30-year-old male diagnosed with PLCH presented for atypical resection of the left upper and lower lobes, partial pleurectomy and talc pleurodesis via VATS. He was a former smoker and had been transferred from another institution for recurrent left pneumothorax. The procedure was performed under locoregional anesthesia and sedation. Single-shot paravertebral block was placed under ultrasound guidance at levels T2 to T8 with levobupivacaine 0.5%, 5 mL per level. Sedation was performed with ketamine and dexmedetomidine infusion. Multimodal analgesia was administered. The surgery was completed with minor blood loss and the patient was discharged after five days without complications.

VATS under locoregional anesthesia is feasible and has been associated with faster postoperative recovery, better postoperative analgesia and shorter length of hospital stay. In patients with interstitial lung disease, lung biopsies performed via VATS also showed a reduction of postoperative morbidity, mortality, reintervention rates and unplanned ICU admissions. Therefore, VATS under locoregional anesthesia should be considered in selected patients with high risk for complications under general anesthesia.

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

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

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

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

Timely and effective analgesia in the Emergency Department (ED) constitutes an important element of patients’ therapeutic approach.The potential of implementing Peripheral Nerve Blocks (PNB) in plenty of injuries and pathological situations and the fact that they spare the adverse effects of systemic analgesia makes them very useful at the ED setting. We aimed to review the literature regarding the PNBs in ED.

Research of the literature was carried out in two databases, Pubmed and Cochrane, using the following free- text terms: (peripheral nerve blocks OR nerve blocks OR regional nerve blocks) AND (emergency department).

953 studies were identified initially and 107 papers were included in this literature review. They were categorized in 4 groups: PNBs of the upper extremity (27), of the lower extremity (51), of the trunk (20), of the head (9). The most common causes of implementing a PNB in ED were: analgesia for closed reduction in shoulder dislocation or forearm fractures, analgesia in hip fractures, analgesia in rib fractures and analgesia in primary headaches respectively. Analgesic effect of PNBs is comparable to that of systemic analgesia. Additionally, PNBs contribute to haemodynamic stability, avoidance of sedation, early ambulation, prevention of chronic pain and reduction in length of stay and healthcare cost.

The use of PNBs in ED is advantageous both for the patient and the healthcare system. However, the existing literature, for specific PNBs especially, proves to be insufficient. Conducting further studies in order to substantiate the efficiency of PNBs in the ED, is of great importance.

The prevalence of obesity has risen dangerously during the last years. In addition, surgery in this type of patients has increased, including the bariatric surgery. Overweight patients usually have associated respiratory and cardiovascular disorders that will be affected with the use of opioids. Multimodal approaches, like opioid-free anaesthesia, regional anaesthesia, can help to avoid the use of opioids and their secondary effects.

A 44-year-old woman was scheduled for elective laparoscopic gastric bypass. Her body mass index (BMI) was 50 kg/m2 and her medical history included asthma and obstructive sleep apnea-hypopnea syndrome. In the operating room, she was monitored with continuous electrocardiogram, pulse oximetry, non-invasive blood pressure monitoring. General anesthesia was performed, fentanyl 1mcg/kg, propofol 2mg/kg, rocuronium 0.6mg/kg. Due the possibility of difficult intubation, videolaryngoscopy was used and the patient was successfully intubated. Ultrasound guided transversus abdominis plane (TAP) block was performed bilaterally. 15ml of 0.25% bupivacaine was injected in each side. During the procedure, 2% sevoflurane was administered, and paracetamol 1 gr and ondansetron 4mg iv were given before extubation. She was extubated and taken to the recovery room, with a Visual Analog Scale score of 1.

Anaesthetic management in patients with morbid obesity is a challenge for anesthesiologists due the morbidities these patients have. It is recommended to apply multimodal strategies, like regional anaesthesia, that produces correct perioperative pain management.

TAP block reduces the need for opioids, minimizing their adverse effects. This technique prevents and relieves the pain that is common after these surgeries, causing a high morbidity.

Postdural puncture headache (PDPH) is usually benign and resolves with conservative therapy. However, it can significantly impact daily activities and postoperative/postpartum recovery. When inappropriately managed, it can result in chronification of symptoms or in potential life-threatening conditions, such as cerebral venous thrombosis.

A 30-year-old pregnant woman, ASA II, underwent epidural catheter placement for labour analgesia without complications. She had an uneventful eutocic birth. 7 hours after the neuroaxial procedure, she had developed a frontal headache (10/10 on verbal numeric pain scale) with postural component. After 3 days of conservative treatment for PDPH, the pain persisted, and a bilateral sphenopalatine ganglion block was performed without analgesic effect. On D4, an epidural blood patch (EBP) was conducted with symptomatic improvement (VNRS 10→2). The following days, the headache worsened, accompanied by tinnitus, hypoacusia, photophobia and inability to abduct the eyes. An MRI was performed and revealed “intracranial hypotension with possible recent cortical vein thrombosis”. After multidisciplinary discussion, it was decided to continue treating intracranial hypotension. On D7, a second EBP was performed with symptomatic remission, leading to the patient’s discharge on D9 and referral to a cerebrovascular specialist.

Intracranial hypotension secondary to PDPH can result in cerebral venous thrombosis. Recent recommendations suggest EBP for PDPH refractory to conservative therapy and with impact on daily activities. Although no ideal timing for EBP has been established, it provides symptomatic relief and potentially decreases neurological sequelae of intracranial hypotension.

EBP is considered the gold standard therapy and should not be postponed in patients with refractory PDPH.

Epidural anaesthesia remains the gold-standard for labour analgesia due to its superiority over other alternatives. However, patients with Brugada syndrome pose a significant challenge due to the risks of local anaesthetics triggering malignant arrhythmias. We present the case of a primigravid patient who had a combined spinal-epidural technique for labour analgesia.

A 40-year-old primigravida patient presented in early labour at 39 weeks gestation and requested for a normal vaginal delivery. Her past medical history was significant for Brugada syndrome that was diagnosed based on ECG findings and a positive family history. Following a multi-disciplinary consult between obstetrics, cardiology and anaesthesiology, an analgesia and delivery plan was formulated for her. Initial analgesia control would be provided by patient-controlled analgesia (PCA) with remifentanil, escalating to a combined spinal-epidural should her pain remain unbearable.

Her labour progressed and as her contraction pains got more severe, she was started on a PCA remifentanil. Subsequently, the contraction pains became unbearable despite escalation of the PCA remifentanil settings. Hence, a combined spinal-epidural was performed but no epidural medication was administered initially in order to minimise the amount of local anaesthetic delivered. When the spinal component started wearing off and her contractions became unbearable again, a low dose epidural infusion was started to good effect and the patient delivered a healthy baby uneventfully.

Labour epidural with local anaesthetics can be administered safely to parturients with Brugada syndrome, as long as safety modifications and appropriate caution is practiced.

An 18-year-old primigravida lady whose gestational age was 40 weeks presented with pushing- down pain and a gush of liquor of 02 hours duration. She was admitted with 3rd -trimester pregnancy + rupture of membrane+ latent first stage of labor. Later on, cesarean section delivery was decided for failed augmentation. Vital Signs in the operation theatre: BP=130/70, PR=98, RR=22, SPO2 =95% on room air. The airway assessment was reassuring. Aim: Experience Sharing

A Case Report using patient charts, perioperative records and management approaches.

Spinal anesthesia was provided under a possible aseptic technique using 2ml of 0.5% isobaric bupivacaine in the sitting position between L3/L4 with a 24 gauge spinal needle. Both the desired sensory & motor blockade was achieved and she was continuously monitored with non-invasive BP, pulse oximetry and ECG. After 20 minutes of spinal anesthesia and delivery of the fetus & placenta, the patient suddenly lost consciousness which was followed by cardiac arrest. Immediately before the loss of consciousness, she was hemodynamically stable. Cardiopulmonary resuscitation was promptly started and 1mg of intravenous adrenaline was given. After 2 minutes, spontaneous circulation was returned. Then she was intubated and transferred to the intensive care unit for post-cardiac arrest care. She was successfully extubated after 10 hours of full recovery and transferred to maternity ward.

All anesthesia providers should be aware of the possibility of subdural block during neuraxial anesthesia. Once subdural injection is suspected, it is advisable to start early resuscitation and avoid further hemodynamic and neurologic complications.

Treacher-Collins syndrome (TCS) is an autosomal dominant disorder with craniofacial deformities arising from developmental anomalies of branchial arches. We report a patient with TCS presenting for caesarean section (CS) and how regional anaesthesia circumvented the management of an almost-impossible airway.

An obese 31-year-old primigravida (BMI 42) required Ex-utero Intrapartum Treatment (EXIT) procedure for management of foetal mandibular hypoplasia. To facilitate EXIT, she was planned for elective CS under general anaesthesia (GA). The patient presented with preterm labour, prompting earlier action. Airway examination revealed micrognathia, microstomia, jaw malocclusion, and thick short neck. She was previously tracheostomised twice. There was documented difficult airway during recent surgery. Fibreoptic techniques had failed due to copious secretions. There was an unfavourable laryngeal view (grade 4 Cormack-Lehane) despite using a hyperangulated blade video laryngoscope. After discussion with relevant stakeholders, she underwent semi-urgent CS without EXIT the following day after consideration for the maternal airway. A combined spinal-epidural was performed with ultrasound guidance. Hyperbaric bupivacaine 11.5mg and fentanyl 15mcg was delivered intrathecally. Epidural space was located at 7.5cm from skin and a catheter was inserted. CS was uneventful.

We described a parturient with exquisite airway challenges (obesity, TCS with craniofacial deformities, previous tracheostomies, and known difficult airway) mitigated with regional anaesthesia. With improvements in healthcare, patients with congenital diseases are expected to survive to adulthood. Being cognizant of the anaesthetic challenges associated with their condition and planning for it is essential for clinical management. Early involvement of a multidisciplinary team facilitates discussion and planning of perioperative management.

Placental abruption is a serious obstetric complication characterized by the premature separation of the placenta from the uterus. It is relatively rare but places the well-being of mother and fetus at greater risk. While the clinical presentations can vary, pain during epidural labor analgesia is not typically associated with this condition and often associated with epidural failure.

We report the case of a 21-year-old primigravida who experienced unusual severe pain during epidural analgesia for labor. Despite initial effective pain relief with epidural analgesia with levobupivacaine 0.125% and fentanyl 2mcg/ml, the patient reported sudden onset of severe localized pain with tetanic uterine contraction, which was initially attributed to epidural failure. However, further evaluation and examination along with the obstetric team revealed an underlying placental abruption. The patient was then underwent category 1 caesarean section under general anesthesia. The baby was born with APGAR score of 9. Intraoperative findings confirmed the diagnosis of placental abruption. Epidural top up was used for postoperative analgesia.

The patient remained hemodynamically stable during the operation. The mother and the newborn had favorable outcomes postdelivery. Patient was satisfied with epidural analgesia on follow up visit.

The unusual presentation of pain during epidural analgesia prompted a timely diagnosis and intervention, highlighting the importance of vigilance for atypical signs of serious obstetric complications during labor epidural analgesia. This case underscores the need for anesthetist as well as other healthcare providers to evaluate for a cause that could be more serious when patients report atypical pain during epidural labor analgesia.

ED50 and ED95 values for hyperbaric bupivacaine with opioids for CS in singleton pregnancy were reported as 7.6 mg and 11.2mg. Low-dose sequential combined-spinal epidural anaesthesia (CSEA) is used for adequate anaesthesia and to minimise side effects. The higher spread of spinal anaesthesia was reported in parturients with multiple pregnancies. We present 3cases of triplet pregnancies in which elective C-section(CS) was performed successfully using a low-dose CSEA.

Case 1: A 28-year-old primigravida with a triplet pregnancy underwent elective CS at 34 weeks gestation. The patient received CSE with 5mg of hyperbaric bupivacaine, 25μg of fentanyl, and 100μg intrathecally. An epidural catheter was placed at L3/4. The patient was supinely positioned with left uterine displacement and received colloid fluid as a coload infusion. The sensory block before surgery was T4, and no vasopressor was required until delivery. Oxytocin, methylergometrine, and prostaglandin were administered for atonic bleeding. No additional epidural bolus was necessary during the CS. Case 2: A 33-year-old at 35 weeks, following the same anaesthesia as Case 1. The sensory block was T3, and phenylephrine was administered as needed before delivery. Additional epidural administration was not required during the CS. Case3:A 30-year-old at 35 weeks gestation, the sensory block was T8 with the same anaesthesia as Case 1 and 5ml of 1%-lidocaine was administered to extend the level. The block level achieved T4 before surgery, and phenylephrine was administered as needed. No additional epidural bolus was required.

Low-dose sequential CSE provided an appropriate anaesthesia for triplet pregnancies.

Regional Techniques are preferred during pregnancy for surgeries due to increased risks of general anaesthesia. We discuss a case of a 28-year-old nulliparous woman at 32 gestational weeks (H:160cm, W:70Kg) presenting with a subcapital hip fracture.

Total Hip Arthroplasty was planned under epidural analgesia. Patient was in supine position with extended hip and externally rotated reporting VAS pain scores 09-10. Under ASA monitoring,Suprainguinal Fascia Iliaca (SFI) was identified using a high frequency linear ultrasound probe placed in a transverse orientation over femoral crease and laterally after palpating the Anterior Superior Iliac Spine (ASIS).Using in-plane technique, the block needle was inserted under the inguinal ligament. After negative aspiration, 20mL Ropivacaine 0.2% was administered deep to the fascial plane. Patient was able to sit for an epidural catheter which was sited with LOR technique. A test dose of 3mL Lidocaine 2% was followed with 5 mL of 0.75% Ropivacaine at 30 min.The THR was successfully concluded at 90 minutes.

SFI block to femoral and lateral femoral cutaneous nerves enable the patient to sit for the epidural. Maternal haemodynamic stability and uteroplacental blood flow were maintained and foetal hypoxia was avoided. Post-operatively, no further analgesia was required and the epidural catheter was removed after 24 hours. Following discharge after 3 days, she gave birth at term.

Regional Anaesthesia is effective and safe for joint arthroplasty during the third trimester of pregnancy.

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

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

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

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

It has been established that hypoxanthine, xanthine and uric acid are present in the brain, their content changes after ischemia, uric acid is the end product of purine degradation in the brain, xanthine oxidase is also present in the brain, catalyzes the oxidation of hypoxanthine to xanthine, and then to uric acid, and can be a source of free radicals. The results of many years of studies of the effects of parenteral use of uric acid in acute ischemic stroke have been published; it has been established that its parenteral administration in patients with cerebral stroke can reduce secondary reperfusion damage to ischemic tissue, and improve the neurological outcome.

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

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

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

von Willebrand’s disease (vWD) is an autosomal dominant condition resulting in deficiency in von Willebrand Factor (vWF) either quantitatively or qualitatively. Parturients with vWD are at increased risk of peripartum haemorrhage, and neuraxial anaesthetic may cause increased risk of spinal or epidural haematoma formation.

A 30-year-old primigravida with vWD 2A and scoliosis presented at 39+3/52 for induction of labour. She had been seen by Haematology at 11 weeks to determine suitability for epidural, with potential need for factor VIII transfusion should factor levels not rise sufficiently in labour. vWF Antigen (vWFAg) levels rose to 113 in week 35 and vWF Activity levels increased to 98 at 35 weeks. Haematologist advised that no prophylaxis was required for epidural, but advised to start IV tranexamic acid when in labour until 1 week postnatally. The patient was counselled regarding potential difficult epidural, with need for repeated attempts hence increased risk of bleeding in view of her background of scoliosis. Continuous spinal-epidural was performed uneventfully. Epidural worked well and was removed 1h post delivery with no complications. Estimated blood loss during delivery was 250ml. Factor VIII, vWFAg and vWF activity levels checked on day 1 post-delivery were acceptable. The patient was discharged well.

Epidural haematoma is a rare but potentially devastating complication post-epidural. vWD patients are at increased risk due to their bleeding diathesis. Close follow up and multidisciplinary discussion between patient, anaesthetist and haematologist is required prior to proceeding with neuraxial. Factors increasing difficulty of epidural e.g. scoliosis also need to be considered.

Congenital Complete Atrioventricular Block (CCAVB) is a rare and potentially serious condition with an important morbi-mortality risk. Treatment, when appropriate, involves implanting a permanent pacemaker. Currently, there are no specific guidelines for the anesthetic management of pregnant women with CCAVB.

Description of the anesthetic management during a cesarean section for a pregnant woman with CCAVB with no pacemaker.

A 29 year-old primipara was admitted for elective C-Section at 35 weeks due to severe pre-eclampsia. She had asymptomatic CCAVB and controlled Crohn's disease. A multidisciplinary meeting was convened to plan the surgery. On the day of surgery, multifunction pads were placed on standby and an arterial line to continuously monitor blood pressure. A cardiologist was on-site and the electrophysiologist team was forewarned of possible emergent need for transvenous pacemaker. An adequate preload was done according to TTE findings before realizing the epidural block for which a total of 16mL of ropivacaine 0,75% plus 10mcg sufentanil were injected in 20min in bolus of 3-5mL. The surgery was uneventful, without the need for pacing nor use of vasopressor/chronotropic drugs, and a healthy baby was delivered. The patient had an uneventful 24-hour stay in level 2 critical care, being discharged at the third day, without complications.

We show a successful case of an epidural block in a CCAVB pregnant patient with no pacemaker. The approach to this population should be multidisciplinary. The decision to place a prophylactic temporary pacemaker should be individualized, but a team should be ready to emergently implant one.

We report a case of brachial plexus anesthesia in a twin parturient with history of epilepsy and gestational hypertension. A 40-year-old woman at 26 weeks of gestation presented in Emergency Room with a traumatic proximal right humerus fracture. She was scheduled for orthopedic surgery which was performed using a two-site ultrasound-guided brachial plexus block to maximize odds of complete anesthesia while minimizing the risk of phrenic nerve paresis.

After an interscalene block with 0.5% levobupivacaine 8 mL, we translated our ultrasound probe caudally to subclavian artery. An additional injection of 0.5% levobupivacaine 12 mL was administered at this site, and the patient subsequently underwent successful surgery without sedatives or analgesics, aside from local anesthetics. Ctg monitoring was obtained during the entire procedure and any abnormalities in the fetal heart rate was recorded. In the post-anesthesia care unit, she had normal respirations and oxygen saturations breathing room air, denied any shortness of breath or difficulty breathing.

There is a high risk of concomitant frenic nerve blockade providing anesthesia with brachial plexus block, and for this reason we assumed, that unlike most healthy patients, a parturient would demonstrate some clinical signs and/or symptoms of hemidiaphragm paralysis, given that the diaphragm is almost totally responsible for inspiration in the term parturient.

The most important advantage of brachial plexus block is that it allows for the avoidance of general anesthesia and the risk of any changes in systemic blood pressure and oxygenation. This represents the third brachial plexus block in a parturient

Neuraxial analgesia is preferred for labor pain, but carries risks of inadvertent intravascular injection. A retrospective analysis found a 0.25% incidence of epidural catheter migration into the vascular space.

Description of a case of intravascular migration of a previously functioning epidural catheter for labor analgesia. Informed consent obtained for publication.

A 34-year-old primigravida, ASA-II, with 37 weeks twin pregnancy requested epidural analgesia for labor pain relief. Using an 18G Tuohy needle at L3-L4 space, a multi- orifice 20G epidural catheter was inserted, with confirmed loss of resistance at 5 cm from the skin. During catheter insertion, blood reflux occurred, which resolved after saline flushing and fixation at a depth of 9 cm. Subsequent tests showed negative blood aspiration and no blood drainage with gravity. An 10mL bolus (8mg ropivacaine with 10mcg sufentanil) was administered in divided doses. Two hours later, due to recurrent pain, 6mL of 0.2% ropivacaine was dispensed. After 30 minutes, the pain remained, and no evident sensory block was observed. Despite negative aspiration, 5 mL of 2% lidocaine was injected, resulting in perioral paresthesia and metallic taste, without hemodynamic manifestations. Suspected intravascular administration was confirmed by a positive aspiration test, with symptoms resolving within 10 minutes without intervention. The catheter was removed and repositioned in another intervertebral space and labor proceeded uneventfully.

This case highlights the possibility of migration of a previously functional epidural catheter into the intravascular space. Anesthesiologists should continuously monitor for signs of LAST despite negative aspiration results.

Non-obstetric surgeries during pregnancy are rare (2%), presenting anesthetic challenges. Retroperitoneal cysts during pregnancy are extremely uncommon, with only seven cases reported between 1955 and 2008.

Description of the anesthetic approach to a large intra-abdominal mass in the third trimester of pregnancy. Informed consent was obtained.

A 34-year-old woman, 2G1P at 28 weeks gestation, ASA-II, presented with a right adnexal mass detected at 19 weeks gestation via ultrasound (120x60mm). A MRI at 26 weeks described a large cystic formation (150x83x76mm) in the right adnexal region with slight compression of the uterus and right colon. Despite being asymptomatic, midline infraumbilical exploratory laparotomy was suggested due to rapid mass growth and considerable size. Preoperatively, fetal lung maturation protocol and tocolysis were administered. Standard ASA monitoring and oxygen supplementation were ensured. A combined spinal-epidural anesthesia was performed using a needle-through-needle technique at the L3-L4 level, with intrathecal administration of 8mg bupivacaine and 2.5mcg sufentanil. Sensory level reached T4. During the surgery, the patient remained cooperative and hemodynamically stable without epidural reinforcement or sedation. Intraoperatively, cystic lesion was found in the retroperitoneum; due to the gravid uterus challenges, excision was deferred. Cardiotocography before and after surgery showed no abnormalities. Postoperative period uneventful, discharged after 2 days. A conservative approach with thorough clinical monitoring was adopted, with scheduled retroperitoneal mass removal after delivery.

Besides the rarity of retroperitoneal cysts during pregnancy, very few cases of awake laparotomy for non-obstetric surgeries in pregnant women are described in the literature.

Familial amyloidotic polyneuropathy (FAP) is an autosomal dominant disorder, with notable clusters in Portugal, Japan, and Sweden. FAP is characterized by the deposition of amyloid fibrils in multiple organs, leading to sensory, motor and autonomic polyneuropathy.

Description of labor analgesia management in a pregnant woman with FAP.

A 35-year-old pregnant woman at 36 weeks gestation requested analgesia for spontaneous labor. The patient has FAP with sensory-motor and autonomic neuropathy, along with a permanent pacemaker. A multi-orifice epidural catheter was placed at the L3-L4 level. An initial bolus of 5mL of 0.1% ropivacaine with 10 mcg of sufentanil provided insufficient analgesia. Thirty minutes later, an additional 5 mL of the same solution was administered, providing adequate pain control for 3 hours. Due to recurrent pain, a total of 9 mL of 0.1% ropivacaine was administered over the following hour. Subsequently, eutocic delivery of a healthy newborn occurred. Throughout labor, the patient was advised against ambulation for safety. No neurological or hemodynamic changes were observed during labor. One month postpartum, the patient exhibited aggravated muscular weakness in left hallux extension (grade 0/5 versus 2/5 prepartum) and bilateral hallux flexion (grade 3/5 versus 4/5 prepartum) with no other new changes noted.

Labor management for pregnant women with FAP should involve a multidisciplinary approach. There is no evidence that epidural analgesia exacerbates pre-existing neurological deficits, hence the recommendation to use less neurotoxic drugs. Further research is warranted to optimize anesthesia/analgesia techniques for pregnant FAP patients.

Narcolepsy is a central hypersomnolence disorder characterized by excessive daytime sleepiness diagnosed by multiple sleep latency test coupled with polysomnography. In narcolepsy type 2, cataplexy is not present and hypocretin levels are normal or have not been evaluated. These patients undergoing surgery are at risk of several adverse events, such as worsening symptoms and perioperative complications. Obstetric patients may be at increased risk during their pregnancy and deliver.

A 36-year-old pregnant woman, ASA-PS II, was scheduled for a c-section due to pelvic presentation. She had type II narcolepsy, obsessive compulsive disorder and depressive disorder, medicated with sertraline. She was intolerant to modafinil. She was a tobacco and cannabis smoker, which she suspended in the first trimester. Pregnancy was uneventful.

She received a sequential combined spinal epidural anaesthesia, and heavy bupivacaine and sufentanil were administered intrathecally. She needed ephedrine after spinal anaesthesia, in a total of 40mg. Intraoperative period was otherwise uneventful. Post-operative analgesia avoided opioid administration and privileged nonsteroidal anti-inflammatory drugs, paracetamol, and epidural analgesia with ropivacaine boluses, and she reported no pain.

The anaesthesiologist must be aware of the implications surrounding narcoleptic patients. Perioperative complications may include altered sensitivity to anaesthetic agents, delayed emergence from anaesthesia, intraoperative awareness, and uncontrolled pain. Given the scarcity of cases described in the literature, it becomes relevant to continue sharing clinical experiences with these patients.

Pyrexia and shivering are the most popular side effects of postpartum administration of misoprostol. However, other side effects can be present and are very rare. We present a case of a 33-year-old post-partum woman admitted to the recovery room who presented delirium with shivering, malignant hyperthermia (MH) and tachycardia after misoprostol administration. We aim to demonstrate that although MH and cardiac dysrhythmias are very rare side effects of misoprostol administration, these should be acknowledged and not undervalued.

The vaginal delivery was discotic and performed under epidural analgesia. 25 IU of oxytocin were administered right after placental removal for uterine atony prophylaxis and about 3h after, 4 rectal tablets of misoprostol (800 mcg total) were used due to uterine relaxation and mild hemorrhage. Both were controlled along with an onset of delirium, severe tachycardia (192/min) and high fever (41ºC). 5mg of intravenous diazepam was administered to control the altered mental status with 1g of paracetamol and 1g of metamizole to lower the temperature. ECG results revealed sinus tachycardia.

She was admitted to the ICU and discharged two days later. Hemodynamic stability and euthermia were achieved 8h post misoprostol administration and a cranial CT scan showed no alterations.

Although 800mcg of misoprostol is considered the standard dose in the last FIGO guidelines, its side effects are dose-related and even rare ones as hyperthermia should be taken into consideration in these cases, especially in deliveries under general anesthesia with volatile anesthetics or other triggers for MH.

Neuropathy following vaginal delivery can result from various factors such as manipulation, lithotomy position, fetal compression, prolonged labor or anesthesia procedures. When a neurological complication occurs in a patient who received regional anesthesia, anaesthesiologists are typically the firsts to be consulted. (1, 2)

A healthy 27-year-old primipara received epidural analgesia for labour. The patient did not report any lower extremity paresthesia, numbness or pain during procedure. Vacuum-assisted delivery was performed due to prolonged expulsion, with occurrence of shoulder dystocia resolved with McRoberts maneuver. 3h post-delivery the epidural catheter was removed, and 11h postpartum, the patient reported hypoesthesia, tingling, numbness and muscle weakness in the right lower limb with difficulty walking. Neurological examination revealed extensor apparatus deficit in the right leg and decreased sensitivity in the territory compatible with L4 dermatome territory. No signs of epidural hematoma or central neurological injury were observed. Prolonged labor was assumed as the etiology of the neuropathy. Treatment included NSAIDs, corticosteroids, vitamins B1, B6 and B12, and a progressive regimen of gabapentin, with close neurological monitoring.

Neurological complications from epidural blocks are rare compared to obstetric causes (1). Given the absence of pain or paresthesia during epidural analgesia, technique-related nerve damage seemed unlikely. Prolonged expulsion phase and vacuum use appeared to be more likely contributors to the neuropathy, potentially overlooked due to sensory block.

This emphasizes the importance of thorough neurological examination before and after catheter removal. Although neurological complications may arise from regional anesthesia, anaesthesiologists should consider obstetric causes as more prevalent.

This audit was done at DHMC, Lahore to describe the labour epidural analgesia services. Labour epidural is the gold standard for pain relief in parturient. Date regarding epidural services and complication rate was very much scarce in Pakistan, when compared to developed countries. So, this audit will help us improving the practising standards at nation level.

This audit was done at DHMC, Lahore to describe the labour epidural analgesia services. Labour epidural is the gold standard for pain relief in parturient. Date regarding epidural services and complication rate was very much scarce in Pakistan, when compared to developed countries. So, this audit will help us improving the practising standards at nation level.

This audit was done at DHMC, Lahore to describe the labour epidural analgesia services. Labour epidural is the gold standard for pain relief in parturient. Date regarding epidural services and complication rate was very much scarce in Pakistan, when compared to developed countries. So, this audit will help us improving the practising standards at nation level.

This audit was done at DHMC, Lahore to describe the labour epidural analgesia services. Labour epidural is the gold standard for pain relief in parturient. Date regarding epidural services and complication rate was very much scarce in Pakistan, when compared to developed countries. So, this audit will help us improving the practising standards at nation level.

Facioscapulohumeral muscular dystrophy (FSHD) is the third most common muscular dystrophy, affecting both sexes equally. It is characterised by progressive muscle weakness in the facial, shoulder girdle, and upper arm muscles. As the disease progresses, it may involve truncal and abdominal muscles, complicating the second stage of labor and often necessitating a caesarean section. Understanding the systemic involvement of FSHD is crucial for anaesthetists to safely navigate the peri-operative period. Regional anaesthesia is the preferred method, despite the risks of worsening and prolonged motor weakness. General anaesthesia is reserved for emergencies. Although malignant hyperthermia is not more common in FSHD, caution is advised. Pulmonary involvement, leading to restrictive disease and respiratory muscle weakness, poses significant risks for the parturient.

A 25-year-old pregnant woman with a history of FSHD was admitted for a scheduled caesarean section. Given the risks and challenges associated with both general and regional anaesthesia, combined spinal epidural anaesthesia was chosen in this patient.

The caesarean section was performed under combined spinal epidural anaesthesia without any intraoperative complications. The patient's motor status recovered to pre-operative levels within the usual timespan, indicating a successful management strategy.

Regional anaesthesia, particularly combined spinal epidural anaesthesia, is a viable and safe option for caesarean sections in patients with FSHD, despite the inherent risks of motor weakness and respiratory complications. This case highlights the importance of a tailored anaesthetic plan to address the unique challenges presented by parturients with FSHD, ensuring safety and effective pain management for both mother and child.

Vasa previa is a rare but potentially life-threatening condition to the fetus, where blood vessels traverse the lower uterine segment, risking rupture. Fetal mortality for unrecognized cases is at least 60% despite urgent cesarean section (CS). Antenatal diagnosis and elective CS between 34-35 weeks of gestation can improve fetal outcomes.

A 34-year-old woman, G2P1A0, was admitted through emergency services at 34+3 weeks of gestation in active labor. She was clinically stable without active hemorrhage. A transvaginal ultrasound on admission day revealed a viable singleton fetus with velamentous cord insertion 2 cm away from the internal os, and fetal blood vessels running across the cervix, making the diagnosis of vasa previa. Anesthesiology and neonatal teams were immediately contacted. It was decided to proceed with an urgent CS using a combined spinal-epidural anesthetic technique. The patient was prepared for the risk of intraoperative hemorrhage and the potential need for general anesthesia. The immunochemotherapy service was notified. The fetus was delivered after careful separation of the membranes avoiding vessel damage. There was no postpartum hemorrhage. The baby, with APGAR scores of 6, 8, and 9, was admitted to the neonatal intensive care unit due to prematurity and discharged after 14 days.

The diagnostic of vasa previa, especially during the onset of labor, poses a complex challenge. It can be fatal for the fetus due to compression of fetal blood vessels during uterine contractions. This case highlights the importance of a multidisciplinary approach, where timely and effective interventions significantly improve maternal and fetal prognosis.

The incidence of Eisenmenger’s Syndrome(ES) in pregnant women is 3% and the mortality rate is reported to be 30-50%. Right heart failure, pulmonary hypertension, arrhythmia and hypovolemia are the main causes of mortality. Successful perioperative management of pregnant patients with ES planned for cesarean section is a challenging process for anesthesiologists. We present a case of cesarean section facilitated by dural puncture epidural(DPE) anesthesia with optimal outcome in a pregnant patient with ES.

Case A 28-year-old primigravida (weight 59 kg, height 157 cm) at 34-week gestation was referred to our hospital for VSD with ES. In the operating room, standard monitoring, including SpO2, noninvasive blood pressure, and ECG, was established. The epidural was performed in the sitting position at the L3/4 interspace via the midline approach using a 17-gauge Touhy needle and a loss of resistance to saline technique. The dura was punctured with a 25-gauge, pencil-point needle using a needle-through-needle technique, and spontaneous return of cerebrospinal fluid was confirmed. After observing free flow of CSF, the needle was removed without the injection of any drug. After the negative test dose, we injected a total of 16 mL of bupivacaine 0.50% in 5-mL increments every 2 min through the epidural catheter.

The caesarean section proceeded uneventfully.

It is reported that DPE anesthesia has a faster onset and better block quality than EA anesthesia and has less maternal hemodynamic effects than CSE. İn our case report, DPE techniques can be an option to facilitate caesarean section in pregnant patients with ES.

Post-dural puncture headache (PDPH) is a positional headache caused by cerebrospinal fluid (CSF) leakage after dural puncture during spinal anesthesia or inadvertent puncture with an epidural needle. The headache's mechanism may involve cerebral vasodilation or traction on intracranial structures.

A 28-year-old multiparous woman at 38 weeks gestation presented for vaginal delivery with epidural analgesia. Dural puncture epidural analgesia was attempted using an 18-gauge Tuohy needle, during which CSF was noted to flow freely. After administering 2 mg of isobaric bupivacaine and 15 µg fentanyl, the needle was withdrawn and an epidural catheter was placed above the initial site. Labor was managed with hourly 10 ml boluses of 0.0625% bupivacaine, and delivery occurred without complications. Post-delivery, the patient was advised bed rest and IV hydration, with prophylactic administration of an analgesic containing paracetamol and caffeine. The patient developed severe orthostatic headaches and photophobia 60 hours postpartum and returned to the hospital. Treatment included a greater occipital nerve block and trigger point injection under ultrasound guidance, followed by a transnasal sphenopalatine ganglion block. Relief was noted three hours post-treatment. Follow-up telephone assessments at 24 and 48-hours post-discharge recorded no further headaches or additional complaints.

For refractory PDPH, a combined greater occipital nerve block and transnasal sphenopalatine ganglion block may be beneficial2,3. This strategy addresses multiple pain pathways potentially contribute to the headache, offering a broader scope of pain relief by modulating both peripheral and central pain pathways.

Neuroaxial analgesia is the gold standard for pain management during labor, however, in patients with contraindications such as coagulation disorders, the use of systemic opioids is a feasible alternative. Amongst the various opioids used, intravenous patient-controlled analgesia (IPCA) with remifentanil constitutes the best choice given its rapid onset and offset, rapid metabolism and elimination and minimal side effects to the mother and neonate. It’s also associated with high maternal satisfaction.

A 33-year-old women, ASA III, 40w+3d of gestation, OI 0000, with immune thrombocytopenic purpura for over 20 years with 50.000 platelets was admitted in the pregnancy ward with strong contractions in early latent phase of labor. Given the contraindication for neuraxial analgesia and after discussion with the patient, it was initiated an IPCA with remifentanil without basal perfusion and with bolus of 0,5 mcg/kg with 3-minute lockout. The patient was monitored with pulse oximeter and capnography, and no episodes of apnea and desaturation were recorded. Fetal cardiotocography showed maintained fetal well‐being. For 12 hours labor progressed and cesarian was decided for stationary labor at 6cm. The procedure was done under general anesthesia, without increased blood loss. The puerperium was uneventful. Afterwards, patient satisfaction with labor analgesia was evaluated as better than expected, with mean pain score during labor as 4/10.

Remifentanil is a safe and effective alternative to neuraxial analgesia during labor. IPCA is often used, however, more randomized controlled trials are needed to determine the use for basal perfusion and ideal bolus dosage.

Familial amyloid polyneuropathy (FAP) poses unique challenges in anesthetic management due to its multisystem involvement. We present a case of successful elective C-section in a patient with FAP, highlighting factors influencing anesthetic choice.

A 40-year-old female (ASA III), 67 kg, 162 cm, with FAP diagnosed at 18, on tafamidis (suspended during pregnancy), presented with neuropathic pain, diarrhea and gastroparesis, anxiety/depression, lumbar disc herniation, and smoking history. Neurological examination revealed hypoesthesia below the knees, abolished Achillean and weak patellar reflexes (polyneuropathy disability score I). A normofunctioning DDD ADI pacemaker was implanted for 2nd degree AV block. No cardiomyopathy or orthostatic hypotension was evident. The airway had no signs of predictable difficulty. Coagulation tests were normal.

Following informed consent, general anesthesia with rapid sequence induction was performed, using etomidate, sevoflurane and rocuronium. Intubation was uneventful. The newborn's APGAR scores were 9/10/10. Intraoperative analgesia included fentanyl, paracetamol, and ketorolac. Hemodynamic and electric stability was maintained. Postoperatively, an ultrasound-guided transversus abdominis plane (TAP) block was performed with ropivacaine. The patient had an uneventful recovery.

In the absence of data supporting neuroaxial anesthesia safety in FAP, coupled with potential bleeding risks and disease progression due to medication interruption during pregnancy, general anesthesia in addition to a TAP block for postoperative analgesia was deemed the safest approach. This case contributes to the limited literature on FAP anesthetic management.

Epidural analgesia is commonly used during labor for pain management, but it carries the risk of complications such as catheter migration, resulting in high or total spinal anesthesia. We present a case of previously functioning epidural catheter migration during labor, leading to high spinal anesthesia.

A 29-year-old woman was admitted for labor induction, during which an epidural catheter was inserted for pain management. Following a negative aspiration test for blood or cerebrospinal fluid, the epidural catheter was secured, tested, and a total of 10mL 0.2% ropivacaine with sufentanil was administered, providing pain relief. About an hour later, due to new pain complaints, a 10mL bolus of 0.2% ropivacaine was administered after a negative aspiration test for cerebrospinal fluid.

Shortly afterward, maternal hypotension and lower and upper limb paresthesias developed, prompting intervention by the medical team. The patient was transferred to the OR, and emergency drugs and equipment were prepared. After continuous monitoring, a decision was made to perform a cesarean section due to fetal instability. Due to insufficient blockade and after discussion with the patient, the catheter was removed, and a new epidural catheter was replaced. The cesarean section was performed under epidural anesthesia. The patient was discharged from the delivery room two hours post-delivery and about 12h later, she developed a positional headache, managed with medication and bed rest.

The exact position of the catheter remained uncertain, but intrathecal or subdural migration was suspected, emphasizing the importance of early detection and proper training to manage such complications effectively.

Self-reported pain scores are often used for pain assessments and require effective communication. Observer-based assessments are resource-intensive and require training. We developed an automated system to assess the pain intensity in adult patients via changes in facial expression.

The patients’ facial expressions were videotaped from a frontal view using a customized mobile application. The collected videos were trimmed into multiple 1-second of video clips and categorized into three levels of pain: no pain, mild pain, or significant pain. A total of 468 facial key points were extracted from each video frame. A customized Spatial Temporal Attention Long Short-Term Memory (STA-LSTM) deep learning network was trained and validated using the keypoints to detect pain level through analyzing facial expressions in both spatial and temporal domains.

Two hundred patients were recruited, with 2,008 videos collected and clipped into 10,274 1-second clips. Among these clips, a total of 8,219 (80%) balanced and normalized data were randomly chosen for STA-LSTM training, while the remaining 2,055 (20%) data were set aside for validation. By differentiating the polychromous levels of pain (no pain versus mild pain versus significant pain requiring clinical intervention), we reported optimal performance of STA-LSTM model, with the accuracy, sensitivity, recall, and F1-score being 0.9217, 0.9215, 0.9215, and 0.9215 respectively.

Our proposed solution has the potential to facilitate objective pain assessment in inpatient and outpatient healthcare settings and allow healthcare professionals and caregivers to perform pain assessment with accessible infrastructure.

This study aimed to compare the analgesic efficacy of two approaches to the Quadratus Lumborum Block (QL Block) i.e. QL-2 and QL-3 blocks in patients who underwent total laparoscopic hysterectomy (TLH).

This randomized controlled trial was conducted on 60 patients who underwent TLH under general anesthesia and were randomized into the QL-2 and QL-3 groups. The total 24-hour postoperative fentanyl consumption, time to request for first rescue analgesic and the Numerical Rating Score (NRS) were noted in the postoperative period.

The mean total Fentanyl 24-hour consumption was not significantly different between the groups. In QL-2 it was 56.83 ± 10.94 mcg vs 53.00 ± 12.21 mcg in group QL-3 (p-value- 0.20). The mean time to first rescue analgesia however was more when QL2 block was given at 17.40 ± 2.72 hours vs 19.30 ± 2.27 hours in QL-3 (p-value 0.005). No statistically significant difference in pain was noted by the mean NRS at 1 hour, 6 hours and 24 hours. At 12 hours however, in group QL-2 the mean NRS was 3.27 ± 1.01 and in group QL-3 it was 2.70 ± 1.14 (p-value-0.04)

Both QL-2 and QL-3 blocks appear equally effective for postoperative analgesia after TLH. A statistically significant difference in time to first rescue analgesia and better NRS at 12 hours has been noted in patients who received QL-3 block; however, it may not have much clinical significance.

Self-reported pain levels, such as the Visual Analogue Scale (VAS), allow patients to report pain. If we want to measure the pain in patients who may have impaired consciousness or dementia, we may have difficulty with subjective measurements. This study is aimed to compare the objective measure of Analgesia Nociception Index (ANI) and self-reported VAS, for diagnosing pain in individuals with femoral neck fracture before and after Fascia iliaca blockade (FICB).

Prospective, observative study was carried out in Hospital of Traumatology and Orthopedics, Riga, Latvia. Patients with isolated femoral neck fracture, underwent Suprainguinal fascia iliaca block (FICB), done by anesthesiologist, using Ropivacaine 0.375% - 30.0 ml and ultrasonography. ANI and VAS were measured before and after the procedure (10, 20, 30 minutes), alongside with vital signs.

22 patients were enrolled in the study. ANIm mean value before FICB was 60.05 [44-97], after 10 minutes 73.95 [58-98], after 20 minutes 83.68 [60-98], after 30 minutes 89.77 [78-98]. VAS mean value before FICB 6.09 [3-8], after 10 minutes 3.86 [1-8], after 20 minutes 2.41 [1-8], after 30 minutes 2.09 [1-6]. There was no significant correlation between ANI and VAS before, during or after FICB. Significant correlation was found between VAS and arterial pressure (r=0.466; p=0.002). ANI measures correlated weak with respiratory rates (r=0.487; p=0.022) and heartbeat rates (r=0.548; p=0.008) after FICB.

There was no significant correlation between VAS and ANI despite significant changes in both. But judging by results on their own and observations during study itself, VAS subjectivity was major problem.

TKA is commonly used to treat severe osteoarthritis. Regional anesthesia was successfully added to post-surgery pain management after TKA, helping lower pain scores, reduce opioid use, and minimize side effects. For TKA, literature supports using the adductor canal block (ACB) as part of a pain relief plan, but this technique doesn't cover the entire knee. So, an additional block is suggested to get complete pain relief.

In a multimodal approach to post-operative pain management in a patient who underwent TKA, adductor canal (saphenous nerve) block together with sacral erector spinae plane block were provided. Then, for the surgery, an opioid-free (general) anesthesia was provided through laryngeal mask and desflurane MAC 0,5-1. Ketorolac 30 mg + paracetamol 1 g were administered before emergence. The patient's written informed consent was obtained.

SESPB together with ACB produced 48 hours full knee analgesia (covering antero‑medial, lateral, and posterior compartments) without motor block, representing an advantage for rehab. Paracetamol 1 g 3 a day was administered, with NRS score < 4.

In our experience SESPB showed the potential to offer a full knee analgesia after TKA together with the ACB.

The Serratus Posterior Superior Muscle originates from C7-T2 ( sometimes T3) spinous processes, progressing obliquely and inserting on the lateral of the second to fifth ribs’ angles. SPSM differs anatomically from the trapezius, rhomboid major and minor muscles because is the only muscle that originates from the spinous process and extends deeply into the scapula. Due to this structure, it may theorically be advantageous for local anesthetic diffusion to dorsal ramus and lateral cutaneous branches of intercostal nerve at C3-T7 levels. The aim of this prospective randomized study is to evaluate the postoperative analgesic effectiveness of SPSIP and SAP in patients undergoing breast surgery.

In this study 10 patients were analyzed. Patients undergoing breast surgery, specifically superior-external quadrantectomy, were divided into two groups before the operation. Group SPSIP ( n= 4) with 20 ml 0,5% ropivacaine under ultrasound guided. Group SAP ( n=6) received 20 ml of 0,5% ropivacaine under ultrasound guidance. Oppioid and FANS consumed, VAS scale were recorded at 2, 6, 12 and 24 hours. PONV was recorded in the postoperatory time

Total Opioid consumption in the first 24 hours postoperatively was significant lower in both group. The mean VAS score was 0.6 ( SD =0.8), indicating a very low level of pain in the first 24 hours post-operatively. The average length of hospital stay was one day for all patients.

In the postoperative period following superior external quadrantectomy, both the SPSIP block and the SAP block, resulted in low VAS scales within the first 24 hours.

In our study, we aimed to retrospectively compare the postoperative pain levels of cases where preoperative erector spinae plane(ESP)block was applied for lumbar disc herniation surgery with and without the addition of dexamethasone as an adjuvant.

60 patients were included in the study and divided into three groups.The first group received erector spinae plane (ESP) block with only bupivacaine(GESPB),the second group received ESP block with the addition of 4 mg dexamethasone to bupivacaine(GESPBD),and the third group served as the control group(GK)without any block.Parameters such as heart rate, blood pressures were recorded before and during surgery.Parameters such as heart rate,blood pressures were recorded before and during surgery.Total opioid consumption in the 24 hours postoperatively and postoperative pain were recorded at regular intervals with Numerical Rating Scale (NRS) scores.

GESPBD and GESPB had significantly lower postoperative heart rates than GK.There was no significant difference in postoperative heart rate between GESPBD and GESPB.In GESPBD and GESPB, systolic blood pressure at 1th hour, 2th hours, and postoperatively was significantly lower than in GK The first analgesia requirement hour in GESPBD and GESPB was significantly higher than in GK.The rate of paracetamol-NSAID-opioid usage in GESPBD and GESPB was significantly lower than in GK.

In patients who received erector spinae plane (ESP) block,intraoperative hemodynamics were more stable, and postoperative pain scores were lower.Compared to the control group, these patients had a delayed onset of postoperative analgesia needs, and opioid usage was reduced.We found that adding dexamethasone as an adjuvant did not have a significant impact.

Epidural analgesia is very useful in the postoperative pain management. This prospective, double-blind, randomized trial was done to evaluate the optimal dose of background infusion in the management of post-operative pain in patients undergoing abdominal surgery.

Fifty patients undergoing lower abdominal surgery under general anaesthesia and thoracic epidural analgesia were randomly allocated into two groups after approval from institutional ethics committee and informed consent from patients; Group 1: 50% of the hourly epidural dose (0.1ml/kg) in the form of background infusion (remaining 50% as demand dose); Group 2: 25% of the hourly epidural dose (0.1ml/kg) in the form of background infusion (remaining 75% as demand dose). Primary outcome measure was numerical rating scale (NRS) scores during coughing, and secondary outcome measures were postoperative nausea and vomiting (PONV), requirement of rescue analgesia and rescue antiemetic, hypotension, motor block, sedation, pruritis and respiratory depression; patients were assessed till the morning of third post-operative day.

Post-operative NRS score for dynamic pain was found to be lower in Group 1 than that of Group 2. Post-operative epidural ropivacaine consumption was significantly lower in the Group 1 with 50% background infusion as compared to Group 2 with 25% background infusion (P < 0.05). The incidence of sedation, hypotension, motor block, severity of PONV and requirement of anti-emetic were comparable in the two groups.

Thoracic epidural administration of ropivacaine-fentanyl solution with 50% hourly epidural infusion dose in form of background infusion provides better pain relief as compared to 25% hourly epidural infusion after major abdominal surgery.

POSTOPERATIVE PAIN IS A SERIOUS EFFECT OF SURGERY AND POOR HANDLING OF IT CAN CAUSE A SERIUOS SIDE EFFECT ESPICIALLY IN THORACIC PATIENTS WHICH CAN LEAD TO PROLONGED HOSPITAL STAY AND THE USE OF MECHANICAL VENTILATION

ITS A CASE STUDY ABOUT A MALE PATIENT WHO WENT THROUGH THORACOTOMY AND THE BENIFITS OF USING THORACIC EPIDURAL PCES FOR CONTROLLING HIS POSTOPERATIVE PAIN

USE OF PCEA THROUGH THORACIC EPIDURAL WAS BENFICIAL TO THE PATIENT THAT ALLOWED EARLY EXTUBATION AND LESS HOSPITAL STAY

a young male patient suffering of severe pain due to thigh abscess, the pain was resistant to all conventional methods of pain control, many techniques were used including regional analgesia techniques which were beneficial

ultrasound guided nerve blocks, epidural catheters

using many techniques to control resistant pain are of great value

The most commonly noted adverse effects of pregabalin include sedation, dizziness, peripheral edema and dry mouth. Oculomotor manifestations associated with pregabalin have rarely been reported. Positional upbeat nystagmus caused by pregabalin has not been reported. I report a case of patient who developed vertiginous giddiness and upbeat nystagmus during treatment with pregabalin.

case report

A 36-year-old female patient with recent lumbar intervertebral disc surgeries was admitted. She underwent left L4/5 posterior decompression for left foot drop and numbness 5 months ago. She underwent L4 to L5 posterior decompression and discectomy for right lower limb pain and numbness 3 months prior to this admission. Pregabalin dose was increased 150-50-150mg daily by pain team 20 days prior to this admission to optimize pain control. She complained of severe vertiginous giddiness during turning her head to left and getting up from bed on the day of admission. Bilateral severe upbeat nystagmus was noted during roll test. Upbeat nystagmus was also noted on left side-lying test. The laboratory tests were unremarkable. Brain magnetic resonance image was normal as well. Dose of pregabalin was reduced to 150-150mg daily. Vertiginous giddiness and upbeat nystagmus were resolved within 2 days of reducing pregabalin dose.

Pregabalin binds to the α2 δ-1 and α2 δ-2 subunit of voltage-gated calcium channels. It is known that α2 δ-1 is present in cerebral cortex, hippocampus and cerebellum, and α2 δ-2 is concentrated in the cerebellum. Decreased excitatory inputs from brain, especially cerebellum by pregabalin may result in functional disturbance of the cerebellum.

Retrospective studies have found an association between epidural analgesia and prolonged survival in patients undergoing primary surgery for solid tumor malignancies (1). There is a paucity of high-quality data in the literature regarding the impact of epidural analgesia on the survival of patients undergoing Whipple procedures for pancreatic cancer. One study of patients who underwent Whipple procedures with and without epidurals found that while epidural analgesia was associated with lower rates of infectious and pulmonary complications, there was no difference in 30 and 90 day mortality (2). However, long-term survival was not measured.

We obtained IRB approval on 2/17/2021. Inclusion criteria: pancreatic cancer diagnosis code, Whipple procedure (pancreaticoduodenectomy) CPT code, located at UNC Hospitals from 2014 to 2019. Exclusion criteria: diagnosis code other than pancreatic cancer following surgery, intra-operatively or immediately post-operative death. A retrospective chart review was then conducted on a dataset from UNC’s electronic medical records, Microsoft Excel was used to process the data.

108 patients were analyzed, 95 with epidurals and 13 without. Demographic traits were similar between the two groups (Table 1). The average post-operative survival time for patients who received an epidural was 1108.8 days (SD 756.6). The average post-operative survival time for patients without an epidural was 1022.0 days (SD 755.6), P-value 0.98 (Figure 1).

Despite a trend toward longer survival for patients with pancreatic cancer who underwent a Whipple procedure with an epidural, differences in 5 year survival rates between the two groups was not statistically significant.

The aim was measure the efficacy of intraoperative musculofascial plane infiltration with Ropivacaine during breast surgery in providing postoperative analgesia, 24 hour opioid consumption and detecting the ancillary incidence of postoperative nausea vomiting during the initial 24hours of the postoperative period.

In the study group (48patients), after removal of breast tissue/tumor, the plane of infiltration was identified under direct vision by the surgeon. 30ml of Ropivacaine (0.375%) was infiltrated at 3 points, 10ml in each plane. At PEC1, between pectoralis major and pectoralis minor muscle. At PEC 2, between pectoralis minor and serratus anterior muscle and at serratus anterior plane under direct vision with a 22gauge, 2.5inch intravenous needle. In the control group (48patients) no local anaesthetic was infiltrated. Patients from both groups received the same intravenous anaesthetic agents and muscle relaxants. Patients in both groups received IV Paracetamol and ketorolac in the intraoperative period. Ondansetron was administered prophylactically in both groups to manage postoperative nausea and vomiting. Pain was assessed by the Numerical rating Scale (NRS) at regular intervals in the postoperative period. Tramadol was administered for breakthrough pain.

Pain control was superior in the study group. Tramadol consumption was lower in the study group. The incidence of postoperative nausea and vomiting was lower in the study group.

Three level myofascial plane block is safe, effective, reliable, easy to perform in decreasing opioid consumption, improving postoperative pain control, providing patient satisfaction after breast cancer surgery.

The purpose of this study was to compare the postoperative analgesic requirement of opioid as rescue analgesia, postoperative pain scores, time to ambulation, perioperative blood pressures, length of hospital stay (LOS), and adverse event rates.

This was a retrospective cross sectional observational study of adult orthopaedic patients (ages 18 - 65 years) undergoing unilateral lower limb surgery (25 - CEA and 25 - CPNB), conducted in Evercare Hospital Dhaka, Bangladesh. Approval for the study was obtained from the hospital ethical clearance committee and the duration of the study was 6 months from January 2023 to December 2023.

The CEA group had a longer time to ambulation (62.7 ± 4.93 hours versus 32.5 ± 4.69 hours, p > 0.05). The CEA group demonstrated more postoperative hypotension (MAP: 64.7 ± 3.6 mmHg) than CPNB group (MAP: 76.8 ± 8.3 mmHg) with p > 0.05. There was a significant difference in the length of stay between the CEA and CPNB groups (4.98 versus 2.93, p > 0.05). There was no statistically significant difference between the rates of pruritus, lightheadedness, and altered mental status. The CEA group demonstrated higher rates of constipation (67.9% versus 5.3%, p > 0.05), and urinary retention (45.8% versus 0%, p > 0.05).

CPNB and CEA demonstrated equivalent postoperative opioid use after unilateral lower extremity surgery. A lower complication rate and a decreased time to ambulation were seen in the CPNB group. A prospective multicentre study could further facilitate the incorporation of CPNB in postoperative pain management protocol in Bangladesh.

Abdominal aortic aneurysm (AAA) open repair surgery is one of the most highly invasive procedures, involving a large abdominal incision. In 2019, Tuglar et al. proposed a thoracoabdominal nerve block through perichondrial approach as M-TAPA block, suggesting its potential usefulness in providing analgesia over the thoracoabdominal region. However, evidence is lacking in the literature regarding its effectiveness. This study aims to evaluate the efficacy of a continuous M-TAPA block in AAA open repair surgery.

Postoperative analgesia using a continuous M-TAPA block and fentanyl injection was provided in three cases of AAA open repair surgery wherein epidural anesthesia was not feasible. Postoperative pain was evaluated using a Numerical Rating Scale (NRS) and the number of patient-controlled analgesia (PCA) demands, and the range of loss of cold sensation was assessed.

The results are presented in the following tables. In all three cases, satisfactory analgesic effects were achieved with relatively low fentanyl PCA requirements. No adverse events associated with the continuous block were observed. There was no overlap between the surgical incision site and the puncture site for the M-TAPA block.

This case series demonstrated the effectiveness of a continuous M-TAPA block for AAA open repair surgery. At our institution, we have recently observed increasing requests from surgeons for continuous M-TAPA block in AAA open repair surgery. This technique has the potential to shorten the time to ambulation, reduce opioid consumption, and shorten hospital stay compared to postoperative analgesia using opioids alone or single shots of peripheral nerve block.

Post-hysterectomy pain is a major clinical problem which could lead to impaired physical function and quality of life. The continuation of acute pain into sub-acute pain is a significant risk factor for chronicity. The aim of this study was to evaluate the socio-demographic, surgical, and psychological risk factors for development of sub-acute pain lasting one month or more following hysterectomy.

We conducted a prospective cohort study in 216 women who underwent abdominal or laparoscopic hysterectomy for benign conditions in KK Women’s and Children’s Hospital, Singapore. Preoperatively, socio-demographic characteristics, preexisting pain, psychological vulnerability, intra-operative variables, and postoperative pain intensity were assessed and recorded. Postoperative 4-month phone survey was conducted to assess the presence of sub-acute pain and functional impairment. Logistical regression analysis was used to identify the risk factors for sub-acute pain following hysterectomy.

Of 216 participants, 140 completed the study. The incidence of sub-acute pain after hysterectomy lasting one month and more was 32.9% (46/140). 93.4% women (43/46) with sub-acute pain had impact on their activities of daily living. Independent association factors for sub-acute pain at one month and more were higher education level, lower body weight, having had abdominal hysterectomy, higher pain scores during sitting 24 hours postoperatively. Area under ROC curve of the final multivariate model was 0.811.

Sub-acute pain is not uncommon (32.9%) after hysterectomy. The risk factors for sub-acute pain will guide risk stratification and implementation of individualized therapies that could improve pain management and prevent progression to chronic post hysterectomy pain.

Pre-operative anxiety is associated with increased postoperative pain and opioid consumption. Aromatherapy can help manage anxiety and pain in surgical settings. This study assessed the feasibility of lavender-peppermint aromatherapy tab use and effects on perioperative anxiety and pain in patients undergoing primary total knee arthroplasty.

This study was approved by the Hospital for Special Surgery Institutional Review Board (IRB# 2023-1715) and registered on ClinicalTrials.gov (NCT06045078). Patients who met inclusion criteria and scored greater than 19 on the PROMIS Anxiety Short Form 8a were enrolled starting October 4th, 2023, and data collection was completed on April 3rd, 2024. A total of 30 participants were randomized to intervention, lavender-peppermint aromatab or control, almond oil aromatab for 72 hours starting pre-operatively and replaced every 12 hours. Participants received standardized intra-operative and post-operative protocols.

Participants in the lavender-peppermint group generally wore the aromatabs more consistently than the control group (Figure 1) and reported higher satisfaction with the intervention. Comparing the control and intervention groups, there was no significant difference for anxiety or average pain respectively (Table 1 and 2).

Participants showed high adherence to the aromatherapy protocol; randomization may have influenced the lower adherence in the control group. This suggests it is feasible to offer lavender-peppermint aromatherapy to patients undergoing primary total knee arthroplasty in an orthopedic setting. In our pilot study, we observed no significant impact of aromatherapy on postoperative anxiety or pain relative to a placebo group, but high satisfaction rates.

Inadequately managed post-operative pain is associated with increased morbidity, mortality and could contribute to development of chronic pain. Mechanical temporal summation (MTS) measures nociceptive pain amplification and is negatively associated with acute and chronic pain post-thoracic surgery. We aimed to investigate the association between MTS and acute pain post-hysterectomy, and to determine perioperative risk factors.

This prospective study recruited patients undergoing hysterectomy for benign gynaecological indications from July 2019 to June 2023. The preoperative MTS was assessed as the primary exposure. The difference of MTS scores (difference between 11th and 1st pain scores evoked by von Frey filament), baseline demographics and clinical information were collected. The presence of acute severe pain at 24 hours post-hysterectomy was defined as pain score of 7 or more. Univariate and multivariable analyses were conducted.

Out of 197 patients, 25 (12.7%) reported acute severe pain. There was no significant correlation between evoked MTS and acute severe pain post-hysterectomy. However, univariate analysis showed statistically significant association between difference of MTS scores and presence of acute severe pain (p=0.0518). The multivariable model for acute severe pain post-hysterectomy comprised three factors: difference of MTS scores (adjusted OR (aOR) 1.06, 95% CI 1.01-1.12, p=0.0238), marital status being non-married (aOR 3.62, 95%CI 1.40-9.39, p=0.0081), and presence of moderate/severe pain pre-hysterectomy (aOR 3.01, CI 1.32-6.88, p=0.0090). AUC was 0.726 (95%CI 0.599-0.853).

This study identified association factors for acute severe pain post-hysterectomy. Future studies could explore early individualised therapies for high-risk patients to optimise post-surgical pain outcomes.

Lumbar spine surgery causes severe postoperative pain, which typically persists for at least 3 days. Recently, bilateral ultrasound (US)-guided erector spinae plane (ESP) block has been demonstrated to produce superior analgesic effects than conventional postoperative opioid based analgesia, reducing postoperative opioid consumption and pain scores in patients undergoing lumbar surgery, therefore improving patient satisfaction and recovery In this case report, we describe a rare complication, that to date has not been reported in the available literature. Our patient presented a persistent hypotension period that required norepinephrine infusion for almost 12 hours postoperatively. Here we present the details of this case and a description of possible explanations.

Case report of a 47 year old male is scheduled for elective spine surgery Anesthetic plan consisted of combined anesthesia: total intravenous anesthesia (TIVA) with orotracheal intubation + intrathecal morphine 100 mcg + ESP block at T11 level for postoperative pain management.

Throughout the transanesthesic period, low MAP values were detected below 60 mmHg. so standard management with crystalloids and norepinephrine infussion was started, evaluating posible etiologies. The procedure ended and the patient was extubated with standard procedures. in PACU the patient persisted with hypotension that required the norepinephrine infusion for at least 12 hours after the surgery,

Recent studies in human cadavers cast doubt on the mechanism of action of the ESP block and it has been proposed that there is more than one mechanism of action interacting. To date, no cases of sympatholisis have been described associated with ESPB.

The aim of the study was to analyse the relationship between the preoperative emotional state and the prevalence and intensity of postoperative pain in patients undergoing cardiac surgery, and to explore potential psychological predictors of postoperative pain.

N = 97 patients were examined psychologically before surgery at Dept. of Cardiac Surgery, University Hospital Kralovske Vinohrady, Prague, and on the last day of hospitalization. Pain intensity and five variables of emotional state (Distress, Anxiety, Depression, Anger and Need of Help) were measured using a Visual Analogue Scale (VAS) and Emotional Thermometers.

The average age of the patients was M = 65.5, with a predominance of men (75 %), the length of hospitalization was M = 8.4 (SD = 6.54) days. Patients underwent aortocoronary bypass (47 %), combined procedures (35 %) and aortic or mitral valve surgery (18 %). A standard medical pain management procedure was used after surgery and during hospitalization. The prevalence of moderate to severe pain (VAS > 5) at the time of discharge was 24.7% (n = 24). For this group before surgery, the most important emotional variable were: anxiety (M = 41.9) and distress (M = 39.8), followed by depression (M = 27.1), anger (M = 11.1) and need for help (M = 12.3). Preoperative anxiety and distress resulted as significant predictive risk factors for moderate to severe postoperative pain (p < 0.05).

Psychotherapeutic interventions should be included in pain management in patients with preoperative comorbid emotional problems to prevent persistent postoperative pain.

We present a successful use of ultrasound guided paravertebral block using ropivacaine as postoperative pain control in Myasthenia Gravis patient who underwent video-assisted thoracoscopic surgery (VATS) for thymectomy.

A 57-year-old/F, ASA II, with Myasthenia Gravis (MG), controlled with Pyridostigmine and Prednisone, underwent VATS. Medical history includes hypertension controlled with Telmisartan + Amlodipine, treated pulmonary tuberculosis, and chronic hepatitis B infection. Preoperatively, she received Ondansetron 4mg, Dexamethasone 8mg, and Neostigmine 0.75mg IV. Anesthesia was induced with Midazolam, Fentanyl, Propofol, and Rocuronium with train-of-four (TOF) monitoring to guide dosing. Double-lumen tube (DTL) placement was confirmed with fiberoptic bronchoscopy. Sevoflurane was used to maintain anesthesia, with depth monitored by bispectral index (BIS). For postoperative pain, ultrasound guided single shot thoracic paravertebral block with 0.5% Ropivacaine 20 mL each at T3 and T8 was performed. Sugammadex was given and within 5 mins, patient’s TOF returns to baseline indicating a full reversal of residual neuromuscular blockade. Extubation then proceeded uneventful.

On postoperative days 1 and 2, pain score was 1/10 (NRS). She also received acetaminophen 1,000 mg IV every 8 hours for two days as part of multimodal analgesia, and received no oral or iv opioids. Course in the ward was unremarkable hence sent home post op day 4 with daily follow-up assessment via phone call revealing satisfactory pain control ranging from 2-3/10 (NRS).

Thoracic paravertebral block can be employed for post-operative pain, a minimally invasive technique offering excellent analgesia that optimizes respiratory function, prevents exacerbation of muscle weakness, and hastens recovery following VATS.

Inadequate analgesia after major abdominal surgery is associated with adverse patient outcomes. We aimed to compare the analgesic effect of intrathecal morphine to epidural analgesia in patients undergoing laparoscopic colorectal resection for cancer.

Patients with colorectal cancer undergoing laparoscopic colorectal resection at the University Hospital of Split were divided into the Epidural group or Spinal group. The primary outcome was pain intensity at rest measured with the Numeric Rating Scale (0 = no pain and 10 = worst pain) 24 hours after surgery. Secondary outcome measures were analgesic consumption, time to rescue analgesia, patient satisfaction, quality of sleep, length of hospital stay, time to return of bowel function, and adverse events (such as respiratory depression, nausea or vomiting, hypotension and bradycardia).

Twenty-two patients were eligible, but 5 were excluded due to technical difficulties or conversion to open surgery. Seventeen patients with a median age of 64 years were included (9 epidural, 8 Spinal group). Based on preliminary results, the median pain at rest at 24 hours was 2 (IQR 0-5) in the Epidural and 0.5 (IQR 0-2.75) in the Spinal group. The time to first rescue analgesia was 60 min in the Epidural (IQR 260min) and 45 min in the Spinal group (IQR 63). There was no respiratory depression, postoperative nausea, hypotension, bradycardia, or shivering reported.

Based on preliminary results, patients in both spinal and epidural analgesia groups experienced mild pain (NRS<3) at rest at 24 hours after laparoscopic colorectal cancer surgery. No serious adverse events were currently observed.

VR applications have been applied in various clinical settings for pain distraction and anxiety reduction. We aimed to determine the needs and preferences of local perioperative settings to facilitate the development of a customized VR-based prototype.

Adult patients about to undergo scheduled surgery were recruited in two Singapore public healthcare institutions. Video examples on VR modules and scenarios were shown, followed by a survey to gather preference and feedback on instructional module on surgical journey, mindfulness module, local relaxation scenarios. Demographics, feedback, preferences were summarized based on number (proportion), mean (SD) or median (IQR) as appropriate.

One-hundred patients were recruited with a mean perceived anxiety score of 35.0 of 100 (SD 25.3). The top three reasons that contributed to patients’ anxiety: Concerns on postoperative pain (n=65), having to undergo surgery (n=53), and life-threatening surgical side effects (n=45). Only 38% had experience with VR application. Among the relaxation scenarios offered, patients preferred having nature environments such as park (n=28), beach (n=27), and local iconic sight “Gardens by the Bay” (n=12). The majority of patients (n=66) was receptive in using VR to reduce anxiety and pain; whereas 76 and 70 patients found mindfulness and relaxation scenarios helpful in reducing anxiety and pain, respectively.

Our local population is receptive to the use of VR to reduce perioperative anxiety and pain, and the data may help to further customise to patient needs and preferences to use VR in perioperative setting to improve anxiety and pain.

Effective pain management is crucial during the process of ventilator weaning for patients in intensive care units, as pain experienced during this process can increase respiratory effort. We present a clinical case that highlights the importance of pain control through the use of regional analgesic techniques for early ventilatory weaning.

We present a clinical case involving a 61-year-old woman admitted due to polytrauma following a fall from a second-floor building. This resulted in several primary injuries, including an open fracture of the left tibial pilon, multiple comminuted fractures of the left foot, a fracture of the diaphysis of the right femur and of the lumbar vertebrae L1-L5, necessitating urgent surgical intervention. Following surgery, the patient was transferred to the ICU, where remained sedated and ventilated for four days until sedoanalgesia and ventilatory weaning were initiated. However, the process was hindered by poorly controlled pain perception, with the trauma of the left lower limb being the primary pain trigger. A multimodal analgesic strategy was implemented, incorporating systemic analgesia (Paracetamol, Ketorolac, Gabapentin, and Amitriptyline) and the placement of continuous femoral and sciatic perineural catheters (PNC) on the left side, guided by ultrasound. Twenty-four hours after the placement of both PNC, adequate pain control was achieved, facilitating a successful attempt at ventilatory weaning. The PNCs remained functional for 12 days, after which they were removed, with no complications registered.

Appropriate pain management is essential for ventilator weaning success, with regional analgesia techniques serving as safe and effective options to enhance this outcome.

Delirium is being increasingly acknowledged as a significant adverse event that occurs postoperatively in elderly surgical patients. Upon establishing the diagnosis, the primary objective of delirium therapy is to identify crucial, potentially life-threatening, treatable organic causes responsible for this syndrome.

We present a case of a 70-year-old woman, history of Hypertension, Diabetes Mellitus and hyperlipaemia who was submitted to an uneventful left total knee arthroplasty under general anaesthesia because she had history of previously failed spinal anaesthesia.

After admission to the PACU, she started to report knee pain NPS 9/10. Multimodal intravenous analgesia was initiated. Soon after patient started to become delirious, experiencing confusion, disorientation and maintaining repetitive speech about unbearable pain. Other pathophysiological causes of delirium beyond pain were excluded. None of the systemic analgesia strategies resulted in pain relief. So, a different approach based on regional analgesia were applied. We performed an Adductor Canal nerve block ultrasound-guided with ropivacaine. After a few minutes, resolution of the cognitive symptoms was archived, and the patient reported a pain score of NPS 2/10.

Early diagnosis is the key to the effective treatment for early postoperative delirium and every patient admitted to the PACU should be screened. Risk factors assessment and effective strategies to prevent it should be implemented by routine. If established, treat of causes should be aimed. Pain can be a trigger for delirium and multimodal analgesia with peripheral nerve block can be used even in patient where neuraxial anaesthesia may be difficult.

Tonsillectomy is a common operation and evidence suggests pain management is often suboptimal(1). PROSPECT recommendations for analgesia includes NSAIDs pre or intraoperatively(2); however, type of NSAID is not specified. IV ibuprofen has a more favourable safety profile than ketorolac(3) and comes pre-prepared for infusion, reducing risk of drug error(4). Evidence suggests IV ibuprofen is as efficacious as ketorolac for postoperative pain(5,6), although no studies were specific to tonsillectomy. This project aims to investigate whether intravenous ibuprofen is as effective as intravenous ketorolac for reducing postoperative pain and postoperative opioid use, following tonsillectomy.

This is an observational study. Recovery staff completed a questionnaire for all patients undergoing tonsillectomy between January and October 2023. Data collected: • Type of intravenous NSAID used (Ibuprofen vs Ketorolac vs no NSAID) • Postoperative pain score • Use of postoperative fentanyl Chi-squared test compared pain severity. One-way ANOVA compared fentanyl use and pain scores.

77 patients included: • Received no NSAIDS: n=8 • IV ketorolac: n=31 • IV ibuprofen: n=38 Pain severity most frequently reported was ‘no pain’, followed by ‘moderate pain’ across all groups. There was no significant difference in pain scores or fentanyl use between IV ibuprofen and IV ketorolac groups.

This study suggests IV ibuprofen produces similar outcomes in postoperative pain and postoperative fentanyl use when compared to IV ketorolac. Given the favourable safety profile, IV ibuprofen should be considered as NSAID of choice for tonsillectomy patients. The study was limited by sample size. Further large-scale studies and cost analysis are needed.

Myastania gravis, is a rare autoimmune neuromuscular disease, characterized by auto antibodies to the acetylcholine receptor causing weakness and fatigue in the limb and respiratory muscles. With patient consent and permission, we present a case 24 year old female scheduled for a partial thymectomy via thoracotomy using multimodal postoperative analgesia strategies.

A 24-year-old woman (height 158 cm; weight 49 kg; American Society of Anesthesiologists physical status II) was scheduled for a partial thymectomy via thoracotomy. Preoperatively intravenous immunglobulin was administered and taking routine medication of pyridostigmine. After induction using 150 mg of IV propofol and 0.5 μg/kg remifentanyl, 20 mg rocuronium, the remaining 3 h of general anesthesia using sevoflurane, infusion of remifentanyl without adding muscle relaxant. No need for reversal of the muscle relaxant, extubated successfully. Patient did not accept the thoracic epidural catheter insertion preoperatively. At the end of the surgery, 22-G needle was inserted between the latissimus dorsi and the serratus anterior muscles at the fifth rib midaxillary line and a total of 30 ml of bupivacaine 0.25% was injected with ultrasound guidance. Paracetamol administered at 6-hour intervals, the patient was followed up in the intensive care unit for 16 hours after the operation was taken to the ward.

No complications were encountered, and patient demonstrated high level of satisfaction. Rapid and safe recovery was achieved in this patient with myastania gravis.

Single injection of serratus anterior plane block seems to be a safe and effective for the management of acute postoperative pain after thoracotomy avoiding opioids.

One-act bilateral total hip arthroplasty is increasingly performed as it has a lower risk of major systemic complications and shorter operative time. The procedure may be done in general or neuroaxial anaesthesia, with or without peripheral nerve blocks. Postoperative pain management include NSAIRs, paracetamol, cox-2-selective inhibitors, opioids and nerve blocks. Peng block provides postoperative analgesia and early mobility. It is mostly used in combination with the lateral cutaneous nerve block, which covers the sensory system of the anterolateral part of the thigh.

A 40-year-old patient with bilateral avascular necrosis, BMI 35, ASA II, was scheduled for simultaneous total hip arthroplasty. The surgery was performed in spinal anaesthesia with levobupivacain and intrathecal sufentanil. At the end of the first arthroplasty, the Peng with lfcn block was performed on the contralateral side, and after the procedure on the ipsilateral side, with 0.25% and 0.125% levobupivacain respectively. The patient was sedated with a target-controlled infusion of propofol at a concentration of 1 mcg/mL. The duration of surgery was four hours.

A verbal numeric pain rating scale was obtained for 2 hrs, 4 hrs, and 8 hrs postoperatively. The scores were 2, 3, and 6 when the patient received peroral oxycodone/naloxone, 10/5 mg tbl. On the first postoperative day, the patient denied significant pain and refused analgesics.

One-act bilateral total hip arthroplasty can be safely performed under neuroaxial anesthesia combined with pericapsular nerve group block, lfcn block, and i.v. sedation. This anesthesia option can be considered when performing surgery on both hips simultaneously.

Epidural analgesia has been around for over a 100 years and despite its widespread use, rare complications such as epidural haematomas and infection are still of major concern. To mitigate such complications catheter care is essential. This audit reviews the incidence of unintentional catheter dislodgement in the postoperative period in the non obstetric population.

This is a single centre retrospective analysis of patients with an epidural catheter for postoperative analgesia over a span of 25 months. The data was collected from the local acute pain database used for follow up such patients.

There were a total of 119 epidurals. Accidental epidural dislodgement occurred in 10.8%, of which 8.4% were a result of dislodgement and 1.68% were due to disconnections. Available literature shows that the incidence is between 1.09 - 13% therefore the local rate of dislodgement falls within this range at 8.4%, while disconnections were lower at 1.68% compared to 1.7 - 2.3%. Additionally the average catheter depth was almost 1 cm shallower in the dislodgement group in relation to the entire cohort. Overall incidence was higher in the 71-100 group although most epidurals were done in the 51-70 age range.

With the highest incidence of epidural haematomas occuring on insertion and removal, planned catheter removal is essential due to anticoagulation strategies in the postoperative period. As local rates sit at the upper half of the range, lower dislodgement rates are achievable. Thus more education and guidelines about catheter depth and fixation methods are necessary to further reduce this incidence.

This service evaluation aimed to reassess postoperative pain and opioid requirement following primary and revision elbow arthroplasty and compare them to previous data from 2019.

We collected data retrospectively from January 2020 to December 2023 for patients undergoing elbow arthroplasty. We recorded type of surgery, regional anaesthetic block placed, local anaesthetic used, intraoperative and postoperative opioid consumption and pain scores on days 0, and 1.

Data were collected from 28 patients, in comparison to 22 patients in 2019. The mean opioid consumption (equivalent to i.v. morphine) in the current evaluation was 5 and 10mg on days 0, and 1 respectively. This compares to 14 and 20mg on days 0 and 1 respectively in 2019. Pain scores were also lower than in 2019. Axillary brachial plexus blocks were performed more frequently than in 2019, levobupivacaine was the local anaesthetic of choice, and i.v. dexamethasone was used routinely. The surgical guidelines had changed from 2019; tourniquets were no longer used intraoperatively.

Discussion: We were satisfied that pain scores seemed satisfactory and similar to 2019 and that opioid requirements were reduced. Our use of axillary brachial plexus blocks as an effective block for elbow surgery has increased and use of dexamethasone has become standard. Abandoning tourniquet use may also be contributing to improved postoperative recovery quality. Conclusion: Opioid requirements after elbow arthroplasty procedures have decreased from 2019 to 2023. Changes in anaesthetic and surgical techniques and perioperative use of dexamethasone may have contributed to these changes.

Multiple-level lumbar discectomies are frequently performed to alleviate pain and neurological symptoms caused by lumbar disc herniation. Despite the routine nature of these surgeries, postoperative pain management remains a critical challenge. In this context, we introduce a novel regional anesthesia technique, the Quadro-iliac plane block (QIPB), which targets the posterior aspect of the Qadratus Lumborum Muscle at its attachment to the inner surface of the iliac crest.

Patients were assessed at 0/1/6/12/24 hours post-surgery. This case series included five patients who underwent lumbar stabilization (multi-level discectomies). The blocks were administered before changing the patient's position from prone to supine, with a total of 100mg of 0.25% bupivacaine applied bilaterally (Figure 1). All patients received the same analgesic regimen in perioperative period; 100mg tramadol, 1g paracetamol, and 50mg dexketoprofen intravenously. Additionally, 1g paracetamol was administered intravenously three times a day.

The mean Visual Analogue Scale (VAS) scores at rest were 2.4/1.8/1.8/1.4/3 at 0/1/6/12/24 hours postoperatively, respectively. For VAS scores with movement, the means were 2.8/2.0/1.8/1.8/3.4 at the same time points. None of the patients required rescue analgesia within the first 12 hours. However, three patients required rescue analgesia (100mg tramadol) at the 16th hour. None of the patients experienced nausea, vomiting, or motor blockage.

In conclusion , our findings suggest that the QIPB could be a valuable addition to the arsenal of regional anesthesia techniques for spinal surgeries, providing effective and targeted pain relief with the potential to improve patient recovery and satisfaction.

he anesthesia management of coronary patients is marked by the perioperative challenges of platelet aggregation inhibitors and post-operative pain management, which could lead to ischemic complications. This case involves a coronary patient undergoing surgery for an axillary tumor.

A 49-year-old coronary patient, K. Zahia, with a history of myocardial infarction less than a year ago, presented with left axillary tumor complicated by brachial neuropathy. Pre-anesthetic evaluation revealed ischemic cardiopathy on electrical and echocardiographic examination. Anesthetic Preparation: Discontinuation of Plavix for 7 days and Triatec for 24 hours preoperatively. Premedication with hydroxyzine. Monitoring included ECG, pulse oximetry, end-tidal CO2, and troponin levels. Technical Anesthesia: Regional anesthesia (RA) combined with general anesthesia (GA). Left supraclavicular block (SCB) followed by continuous paravertebral block (CPVB) at T3-T4 level. GA induction with Diprivan, Vecuronium, and Fentanyl, followed by maintenance anesthesia with Diprivan. The CPVB catheter provided postoperative analgesia.

Coronary patient anesthesia requires hemodynamic stability and adequate analgesia to prevent ischemic complications. The combination of GA and RA offers effective pain management and facilitates early rehabilitation.

Optimal coronary patient anesthesia aims for hemodynamic stability and perioperative analgesia to prevent ischemic complications. The combination of GA and RA achieves these goals effectively, promoting early rehabilitation and reducing postoperative morbidity.

Median sternotomy is the traditional method for cardiac surgery. It comes with drawbacks like intense pain, extended hospitalization, and aesthetic issues. Minimally invasive cardiac surgery (MCIS) avoids these disadvantages, enabling faster recovery after surgery. Patients might still experience significant pain due to the involvement of intercostal nerves and rib retraction. The serratus posterior superior intercostal plane block (SPSIPB) is a new technique performed between the serratus posterior superior muscle and the intercostal muscles. We wanted to share our experience with SPSIPBs for MICS in four patients. All patients provided written informed consent.

The patients’ demographics were as follows: male aged 53 years (Patient 1), female aged 35 years (Patient 2), female aged 74 years (Patient 3) and male aged 38 years (Patient 4). Before induction of anesthesia, each patient had SPSIPB applied in the sitting position. After proper placement of the block needle between the third rib and the serratus posterior superior muscle, 40 ml of 0.25% bupivacaine was delivered.

The patients were transferred to the cardiovascular intensive care unit after surgery and were attached to a patient-controlled analgesia device containing morphine. Pain was evaluated using the numerical rating scale (NRS). The NRS scores at extubation time, 1, 6, 12, and 24 h were recorded.

We assessed the effectiveness of SPSIPB in patients who had MICS. SPSIPB may offer effective pain management following MICS. Randomized controlled trials are needed to determine the feasibility of SPSIPB more accurately.

The SpineJack® system uses titanium implants to re-expand broken vertebrae. Locoregional techniques are of particular interest in these interventions. This study aims to investigate whether erector spinae plane block (ESPB) is superior to blind infiltration of local anesthetic in pain control following kyphoplasty with the Spine-Jack system.

We conducted a retrospective analysis of 12 patients who underwent Spine-Jack type kyphoplasty during 2024 at our center. The primary objective was the reduction of VAS (Visual Analogue Scale) values after intervention in patients with ESPB. Other objectives included dose of postoperative rescue morphine, incidence of clinically significant adverse events, and procedure duration.

Of the 12 patients, 4 were performed with sedation and blind infiltration of local anesthetic (Group A), and the rest received ESPB prior to surgical incision (Group B). Poorer post-intervention pain control was described in Group A, with VAS ≥ 6 in 3 of the 4 patients (p<0.01). A lower dose of rescue morphine was noted in Group B, although this result was not significant (p 0.6). Surprisingly, the procedure was shorter in Group B (p 0.5), without differences in other clinically significant adverse events.

ESPB appears to be a safe and effective technique for improving pain control in kyphoplasties. However, given the small group of patients recruited, some of the results were not significant. Based on this descriptive pilot study, we will propose a prospective analytical study to confirm the technique's efficacy.

Major spine surgery (MSS) is one of the surgical interventions with the highest incidence of intense postoperative pain. Given the need to optimize analgesic control in this type of patient, our service began to use pre-incisional intrathecal morphine (ITM) associated with the same multimodal analgesic strategy. Our study aims to assess whether the baricity of ITM alters its efficacy.

We performed a retrospective analysis of 12 patients undergoing MSS between 2022 and 2024. All patients underwent general anesthesia and the same protocol of multimodal analgesia with intrathecal injection of morphine. The postoperative analgesic protocol was similar and included intravenous morphine by PCA pump if pain score >3 on Visual Analogue Scale (VAS). The main objective was the reduction of VAS scores after the use of hyperbaric compared to isobaric ITM. Other objectives described included postoperative rescue morphine dose and incidence of clinically significant adverse effects (pruritus, nausea, vomiting, urinary retention and respiratory depression).

Three series, each of 4 patients are described: 1) Group H200 received 200-280 μg of hyperbaric ITM; 2) Group H300 received 300-350 μg of hyperbaric ITM; 3) Group I received 200-300 μg of isobaric ITM. In Groups H200 and H300 was observed worse pain control after surgery and higher dose of postoperative rescue morphine. With these doses there were no clinically significant adverse effects.

Based on this descriptive study, we will propose to carry out a prospective study to try to establish the most appropriate dose of isobaric ITM in major spine surgery in adults.

Open and combined anteroposterior lumbar spine interbody fusion (APLF) generally has higher pain intensity compared to the posterior approach alone. Our study aims to evaluate whether the use of intrathecal morphine (ITM) significantly improves acute postoperative pain without increasing the incidence of significant adverse effects or length of hospital stay (LOS).

We performed a retrospective analysis of patients who underwent APLF between 2023-2024. All patients underwent general anesthesia and received the same multimodal analgesic regimen with intravenous morphine by patient-controlled analgesia pump. Groups: those who did not receive ITM (control group) and those who received 200 μg of isobaric ITM (ITM group). We analyzed: use of ultrasound (US)-guided interfascial blocks, visual analog scale (VAS) levels, postoperative rescue morphine doses administered during the first 24 h after surgery, and incidence of clinically significant adverse effects (pruritus, nausea, vomiting, urinary retention and respiratory depression) and LOS.

Six adult patients were included. In the Control group, all patients reported a VAS punctuation ≥6, while all ITM Group patients reported a VAS punctuation <3. A higher dose of postoperative rescue morphine was also observed in the Control Group. In Control group, 2 patients received US-guided interfascial blocks, none of ITM group. There were no clinically significant adverse effects and no differences in LOS.

ITM administration has been shown to reduce VAS punctuation after APLF without increasing significant adverse effects or LOS. Based on our results, we will carry out a prospective study to establish the most appropriate dose of ITM in patients undergoing APLF.

Αnalgesia for maxillofacial fractures surgery is mostly based on intravenous opioids while pain management postoperatively is often inadequate. With this case series we aimed to observe the efficacy of Opioid Free Analgesia (OFA) in three patients with maxillofacial bone fractures.

Dexmedetomidine or clonidine was given as premedication and induction of general anesthesia consisted of lidocaine, dexmedetomidine and propofol. Moreover, maintenance of anesthesia and analgesia included lidocaine, dexmedetomidine and ketamine, paracetamol, NSAID, magnesium and dexamethasone. Postoperative analgesia regime included paracetamol and tramadol as rescue analgesia.The intraoperative analgesia was evaluated with the use of NOL monitor (Nociception Level) as well as with vital signs (Blood pressure, Heart rate, Anesthesia depth, EtCO2). Postoperative analgesia was assessed by NRS (Numerical Ratings Scales) and vital signs.

All three patients were men, 27-43 years old and ASA I or II. Their maximum Mean Arterial Pressure (MAP) intraoperatively was 106-120 mmHg, maximum Heart Rate (HR) 86-105 bpm and maximum NOL rate 23-42, all recorded during either intubation or first incision. Otherwise their MAP was kept below 95 mmHg, their HR < 83 bpm and their NOL rate < 20. During the first 36 hours postoperatively, all patients had an NRS score 0-1/10, MAP < 87 mmHg, HR < 80 bpm and only one of them required rescue analgesia.

In this case series, we observed that OFA could achieve the analgesic goals in maxillofacial fractures surgery. Further studies are required to support our observation.

Constant military conflicts in the world and a full-scale war in Ukraine make the study and improvement of pain management relevant. Pain is an unpleasant or painful sensation, an experience of emotional or physical suffering. In general, injuries can be divided into background, breakthrough and procedural pain. There are many pain rating scales that must be used to categorize casualties into levels of pain relief. The modern approach to multimodal analgesia of injuries and wounds is generally accepted in the world. The earliest possible start of high-quality and comprehensive pain relief is the key to the success of analgesia and the prevention of chronic pain. An important place for pain relief at the stages of evacuation and in hospitals is occupied by ketamine, NSAIDs, paracetamol, opiates and regional techniques. Currently, the world is experiencing a flourishing of regional anesthesia, which is especially associated with the nature of combat wounds. A significant part of combat injuries are characterized by damage to the extremities, and this is associated with very intense pain and chronic pain. The most important role is played by the use of ultrasound for precise navigation when performing conduction and planar blocks. In addition, one must remember the mental component of pain and the need to add sedatives when needed. However, further research is needed to improve wound pain management. Future research may be needed on the effects of new analgesics, new regional anesthesia techniques, music, virtual reality, hypnosis, acupuncture, and other modalities on pain relief.

The widespread use of ultrasonography in regional anesthesia in recent years; resulted in the identification of new blocks such as serratus plane block (SPB). SPB is a regional analgesic technique that blocks T2-T9 which has an excellent role in postoperative pain management for cardiothoracic surgeries. We performed a SPB for postoperative analgesia in 5 patients undergoing minimally invasive heart valve surgery (MIHVS).

SPB block was performed after induction of general anesthesia and before the surgical incision, using 1,5mg/kg 0.25% bupivacaine. The pain was measured using a visual analogue score (VAS) (0, no pain; 10, worst pain imaginable) in recovery and at the 6th, 12th, 18th, and 24th hours. VAS was less than 3 for the 24th hour and patients had no need for additional analgesics for a post-block period of 12 hours.

SPB provides prolonged postoperative analgesia in patients undergoing MIHVS. Further randomized controlled trials are needcd to enhance the efficacy of the SPB.

Thoracic pain is thought to be transmitted via nerves originating from T2 to T9. Blockade of unilateral intercostal nerves can provide sufficient analgesia after MIHVS. A combination of opioids, non-steroidal anti-inflammatory agents, and regional methods; with different mechanisms of action in postoperative pain management is considered to be more effective for post­ operative analgesia and minimizes side effects as well as reduces the incidence of chronic pain.

At our centre, we perform ~160 mastectomies annually, with ~50% receiving paravertebral (PVB) or erector spinae plane (ESP) block. Our aim was to conduct a baseline audit of our current practice to quantify post-operative pain outcomes. This could then inform implemented change, with the aim of improving pain outcomes.

Over a 3-month period, we audited 20 patients undergoing mastectomy or mammoplasty. 10 patients received general anaesthesia (GA) with PVB/ESP block. 10 patients received GA with local anaesthesia (LA) infiltrated surgically. Data was collected both prospectively and retrospectively. The key outcomes were - failed day case rate, intra and post-operative opioid requirement, pain scores immediately after surgery, on discharge, day 1 and day 2. Our local audit department authorised this project, confirming it did not require Ethical Committee approval.

3 out of 10 cases that received GA+LA required unplanned inpatient admission due to inadequately controlled pain post-operatively. There were no such cases in the GA+PVB/ESP group. See graphs 1 and 2 for further results.

Our data shows that patients undergoing mastectomy or mammoplasty that received GA+PVB/ESP had reduced intra and post-operative opioid requirements, reduced pain scores up to 48 hours post-operatively as well as being less likely for day case failure due to inadequate analgesia, in comparison to those patients that received GA+LA. After achieving our aim from this initial audit, we will present this data at our clinical governance meeting. Recommendations for change will include PVB and ESP block training, following which we plan to re-audit to measure any improvement.

Acute postoperative pain is often managed with multimodal pain strategies. Clonidine, due to its analgesic properties, may be a relevant component of this approach. Studies suggest that perioperative use of clonidine reduces postoperative pain intensity and opioid consumption. However, previous studies are limited by small sample sizes and questionable study designs. We hypothesized that a single dose of intraoperatively administered intravenous clonidine would reduce postoperative opioid consumption, pain intensity and opioid-related side effects after spine surgery.

This study is a prospective, randomized, blinded, placebo-controlled trial with two arms. Patients (n = 120) scheduled for spine surgery at Aarhus University Hospital were randomized into two arms: an intervention arm that received a single dose intravenous clonidine (3 micrograms/kg) immediately after intubation, and a control arm that received a placebo containing isotonic saline immediately after intubation. Preoperative opioid-users and non-users were randomized separately to ensure equal representation in the two arms (Figure 1). The primary outcome was opioid consumption (intravenous morphine milligram equivalents) within the first three hours after arrival at the Post-Anesthesia Care Unit.

We screened 221 patients out of whom 129 patients were included in the study. In total, 120 patients have completed the study according to the protocol out of whom 31 were preoperative opioid-users and 89 were non-users. Unblinding is anticipated in June 2024 and the final results will be presented at the congress.

Perspectives: Our study is expected to provide valuable information on safe and effective multimodal perioperative pain treatment with intraoperative clonidine.

Multiple sclerosis (MS) is a central nervous system chronic disease that affects millions of people worldwide, causing motor problems, neuropathic pain, and urinary disorders. Controlling neuropathic pain in MS is particularly challenging, with conventional treatments often proving ineffective. In this case, posterior cord stimulation (PCS) was evaluated as a treatment for neuropathic pain in a 73-year-old woman with primary progressive MS and significant functional limitations.

The patient, diagnosed at 62, experienced worsening neuropathic pain in 2019 without relief from conventional therapies. A percutaneous dodecapolar electrode was implanted for PCS. The initial trial resulted in significant pain reduction, leading to the permanent implantation of a subcutaneous generator.

The initial trial with the percutaneous dodecapolar electrode resulted in a 60-70% reduction in pain, which remained stable over time. Following the success of the trial, a permanent subcutaneous generator was implanted, maintaining a 80% pain reduction. This improvement increased the patient's participation in daily activities and reduced the need for analgesic medications. No exacerbations of MS were observed.

This case suggests that PCS is a promising and safe option for managing neuropathic pain in MS, aligning with studies reporting improvements in over 50% of cases. PCS can offer significant benefits in quality of life and pain control for patients with MS refractory to conventional treatment. Neuromodulation technology continues to advance, promising new opportunities for the effective management of this condition.

The objective of this study is to evaluate the effectiveness of autohemotherapy with ozone in the management of fibromyalgia (FM).

20 fibromyalgia patients were treated with 10 sessions of ozone hemotherapy (2 sessions per week) with a concentration of 30-60 mcgr/ml. The health condition of the patients and their pain intensity were evaluated before and after treatment, using Visual Analog Scale (VAS) and measuring the frequency of the fibromyalgia flares.

All patients treated with ozone reported an improvement in sleep and everyday activities, a marked decrease in pain sensation, accompanied by decrease in VAS scores, as well as tender points, and a noteworthy decrease in frequency of fibromyalgia relapses.

The autohemotherapy with ozone in patients with fibromyalgia showed an important decline of tender points and VAS score, as well as a decrease of fibromyalgia flares, facilitating the everyday life of the patients suffering from the disease. This treatment seems to reduce the everyday use of pain medications, diminishing harmful side effects. Further investigation should be carried out, including groups with more patients and clinical trials, to elucidate the effect of ozone therapy in patients suffering from fibromyalgia.

We describe the case of a patient that underwent a series of nerve blocks and pulsed radiofrequency of the ilioinguinal/iliohypogastric nerves for the treatment of chronic pelvic pain. National guidelines in the United Kingdom, NICE clinical guideline 193 (NG193)4, do not recommend interventions in Chronic Primary Pain conditions such as CPP.

She experienced dyschezia and right sided pelvic pain radiating down to the leg, severe enough to keep her awake at night. The pain began after numerous gynaecological surgeries for endometriosis. The patient had baseline pain which was described as 5/10 as well as intense flare-ups described as 9/10 pain. Between December 2018 and August 2022, the patient underwent 5 right sided ultrasound-guided ilioinguinal/iliohypogastric nerve block plus pulsed radiofrequency procedures.

Of the five procedures, four had an extremely positive effect. Each procedure bar one, which was less effective, resulted in up to 80% reduction in pain and reduction in the frequency of flare ups. The repeat blocks with pulsed radiofrequency offered effective pain management that lasted for 9-12 months. As a result, the patient experienced significant improvement in quality of life.

This patient’s clinical history, gave us reason to suspect ilioinguinal/iliohypogastric neuralgia and hence proceeding with the initial diagnostic and therapeutic intervention, to which she responded very well. At every point the patient was consented fully and made aware that they were out of national guidance. The patient continues to receive excellent benefit from an intervention that she receives annually and opts to have the intervention despite the risks reiterated.

Chronic pain affect over a third of the global population aged 25 and older. Regardless of its etiology, it adversely impacts all aspects of life, leading to decreased productivity and diminished overall well-being. The available systemic treatments are effective but exhibit significant adverse reactions with long-term use. Conversely, local treatments demonstrate limited duration of effectiveness, necessitating frequent reapplication. Lidocaine is recognized as an effective local anesthetic; however, it also possesses an analgesic effect with a central mechanism that remains poorly understood. Additionally, Cannabidiol has demonstrated analgesic properties through both local application and systemic use.

To combine the proven effectiveness of both substances, we developed beta-cyclodextrin encapsulated nanoparticles containing lidocaine and CBD. These nanoparticles were incorporated into a gel base for local application. The formulation was tested in vitro using a Franz Cell system and synthetic membranes. The diffusion medium was analyzed to quantify the amounts of both substances that passed through the membranes at 1, 2, and 24 hours using ultraviolet-visible (UV-VIS) spectrophotometry.

The results showed that lidocaine diffused through the membranes primarily within the first two hours, whereas CBD exhibited a significant diffusion rate between 2 and 24 hours.

With just one topical application, the developed formulation could produce long-lasting analgesic effects for up to 24 hours. This formulation has the potential to act as an alternative for a controlled-release transdermal device, a topical product requiring frequent administration, or a systemic pain reliever.

Painful Vertebral compression fractures without neurological involvement caused by severe osteoporosis can significantly burden patients. The severe pain, deformity and limited mobility affect their quality of life significantly.Most of these patients are offered Oral analgesics, Supportive devices, Psychological support, Lifestyle Modifications, Physical therapy, Osteoporosis treatments and in refractory cases Vertebroplasty/ Kyphoplasty.

A 82 year old lady with severe debilitating pain in her lower back, abdomen and bilateral thighs since 2 years presented to us for pain relief. she was in severe pain with NRS 10/10, wheel chair bound with severe functional limitation. X-Ray and CT SCAN Lower thoracic spine and lumbosacral spine AP & Lateral view showed severe compression fracture D1, D6, D 10, D 11, L1,L2, L3.She was planned for vertebroplasty at D11 and L3 level. She also had fixed flexion deformity at both knee and very tight hamstrings making positioning of the patient very challenging.

We performed vertebroplasty at both T11 and L3 levels simultaneously. After obtaining written informed consent from the patient we performed fluoroscopy guided Needle insertion of 11 G at both side pedicles of T11 as well as L3 level. PMMA was injected through the needles in the lateral view simultaneously and procedure was completed with all aseptic precautions. She had good pain relief with NRS 2-3. She was admitted for a day then discharged home with low pain scores NRS: 1/10.

in a resource limited setting where patients suffering from severe osteoporotic compression fracture pain, even in compression <50%, vertebroplasty has a significant role.

Postherpetic neuralgia (PHN) is a common and painful complication of acute herpes zoster. In some cases, it is refractory to medical treatment. Sacral dermatomal involvement occurs in only 3% of patients with PHN. Although rare, these patients can suffer from severely agnozing and disabling pain.

Case report

A 45 year old female visited our clinic with severe intermittent pain in her perineium and urinary incontinence. She had herpes zoster on anal and genital area before 3month earlier. The pain was burning and stiningng with numeric rating scale(NRS) 7 in pain intensity. The patinet took PO medication of neruoapthic pain, but little effect at all. In our clinic, we performed several interventional treatments such as caudal epidural block, ganglion impar block and sono-guided bilateral pudendal nerve block(PNB). The last one, PNB, she said best effect and effect last more longer than other intervention. After 2nd trial, we decided to do pulsed radiofrequency ablation(PRF) on both side of pudendal nerve. and after 2week, her symptom of urinary incontinence was subside and pain was significnatly reduced with NRS 1~2 which last for 8month.

The PNB under image-guidance has lead to a minimal patient discomfort, an increase in patient safety and a favorable outcome. Conventional RF can cause permanent nerve damage by neuroablative thermocoagulation. On the other hand, PRF produces the same voltage fluctuations in the lesion of the target without thermocoagulation. So, PRF is safe and there are few reports of adverse effects. To get a successful outcome, multiple cycles should be performed.

Introduction Chronic postoperative inguinal pain, CPIP has a pooled incidence of 11% -16.8% and it is severely disabling in 2%-6% of cases.1,2 This can be of neuropathic or non neuropathic in origin. Characteristics sharp, burning or 'shooting' sensation is felt in the distribution of ilioinguinal, genitofemoral and iliohypogastric nerves. Management includes analgesics, nerve blocks. trans-cutaneous electric nerve stimulation, pulsed radio-frequency, nerve root blocks. Surgical interventions are considered as the last option when other methods failed.3

Case report A 54-year-old man presented with a history of intractable left sided groin pain for 3 years following left recurrent inguinal hernia repair. Burning type of pain was experienced in groin, scrotum and upper part of inner thigh. No signs of hernial recurrence or radiological evidence of meshoma. Pharmacological management was unsuccessful and nerve blocks gave partial and short term improvement. Laparoscopic retroperitoneal triple neurectomy was done under general anaesthesia transecting the 3 nerves. Marked improvement of symptoms observed in immediate post op period and good quality of life during the review in 3 months after the procedure.

Discussion Inguinal hernia repair is one of the commonest surgical procedures. CPIP is a debilitating complication independent of surgical method.4 Patients require multidisciplinary assessment and non surgical treatment as first line management. All patients should undergo diagnostic and therapeutic nerve block prior to neurectomy. Laparoscopic retroperitoneal approach is minimally invasive, facilitate nerve identification with minimal complications. Effectiveness can be assessed in the immediate post operative period.5

Traumatic brachial plexopathies (TBP) can cause severe neuropathic pain (NP). Opioids are usually recommended second to fifth-line for NP due to significant side effects. TBP patients are at risk of prolonged opioid prescription due to chronic debilitating pain, associated psychological issues including depression and pain catastrophizing. However, TBP patients are commonly prescribed opioids for nociceptive pain caused by concurrent injuries. This case study looks at efforts to minimize opioid use in a young patient who suffered from a left brachial plexopathy and hip fracture following a road traffic accident.

This involved reading published articles on TBP management, the patient's journey with the acute pain service and discussions with his consultant-in-charge.

With daily reviews and re-education while on patient-controlled analgesia (PCA) fentanyl, he was weaned off post-operatively within a week and converted to oral oxycodone. The use of adjunct analgesia in accordance with published guidelines helped to improve NP control. Oxycodone was switched to Targin to reduce constipation risk while retaining analgesic effectiveness. Opioids including oxycodone and tramadol have clinical efficacy in relieving peripheral NP but are insufficient as sole analgesic agents. They are used in conjunction with first line drugs to optimize NP control. Studies recommend starting opioids within one hour of nerve injury to reduce risk of nociceptive hyperalgesia.

First-line treatment with gabapentinoids, tricyclic antidepressants and topicals should commence to optimize NP control. If opioids are started, it should commence within one hour of nerve injury and weaned off once feasible. Regular reviews of opioid prescriptions are vital.

Axial neck pain, a persistent challenge in clinical management, prompts an investigation into the operative details and outcomes of endoscopic cervical rhizotomy. This study presents a case report, emphasizing the precision of the operative procedure and its impact on alleviating axial neck pain.

As the case presentation is devoid of patient identifiable information, it is exempt from IRB review requirements as per Precision Pain & Spine Institute policy. Informed consent was obtained from the patient for submission of the case report.

Performing endoscopic rhizotomy of the cervical medial branch, guided by fluoroscopy, is a viable method for relieving axial neck pain.

Endoscopic Cervical Rhizotomy has the potential to offer effective relief from axial neck pain in appropriately selected patients. Based on randomized clinical trial, percutaneous radiofrequency ablation under endoscopic guidance has advantages of more accurate positioning, more thorough denervation, fewer complications, lower risk, and better long-term efficacy up to 5 years post-procedure.

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

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

A total of 50 patients were included in this study in two transforaminal (T) and caudal (C) groups. Pain score (VAS) and functional disability index (ODI) were similar in both groups, and there was no significant difference between the two groups (p>0.05). The positive Lasègue test was significantly higher in the caudal group than in the transforaminal group only in the third month (p<0.05). Other physical examinations in both groups did not have significant differences in all the follow-ups. Also, there was no difference in the amount of analgesic consumption in the two groups. No complications were observed in both groups.

This study showed that transforaminal and caudal steroid injection (with a targeted catheter) in patients with lumbar radiculopathy had similar effects in controlling pain and improving functional disability of patients in the short term.

Von Willebrand's Disease is an inherited bleeding disorder characterized by a deficiency or dysfunction of von Willebrand factor. Patients with this disease present a challenge in the management of chronic pain due to the high bleeding risk. The purpose of this paper is to highlight the complexity of managing a patient with Von Willebrand and chronic lumbar sciatica.

A 65-year-old male patient, presented to our Hospital's Pain Clinic, complaining of persistent back pain and sciatica on the right for three months. His medical history revealed a prior diagnosis of Von Willebrand disease. Lumbar spine MRI revealed findings consistent with degenerative spondyloarthropathy, spinal canal stenosis at the L4-L5 vertebrae level, intervertebral disc prolapse at L3-L4, and notable narrowing of the intervertebral foramina, particularly on the right side.

The patient was initially treated conservatively with pregabalin, duloxetine, tramadol in a titrated dosage for 6 weeks, without significant improvement of his symptoms. After consultation with his Hematologist, he underwent preparation with Haemate (FVIII/FVW) and then an epidural injection was performed at the L4-L5 level. No bleeding complications were noted from the interventional technique. Remission of symptoms >60% and reduction in analgesic requirements was observed 1 week later.

This case highlights the significance of carefully assessing and managing pain in patients with high bleeding risk, such as those with Von Willebrand's Disease. The benefits and potential risks of interventional techniques must be weighed, and proper patient preparation, interdisciplinary collaboration, and compliance with safety protocols must be a top priority.

The present review provides a comprehensive overview of global health collaborations between high-resource settings (HRS) and low-resource settings (LRS) in musculoskeletal pain management. The review examines the research methodology of the included studies, barriers to conducting global health work, and impact of global health collaborations.

A preliminary search was conducted through PubMed, Google Scholar, and Cochrane in 2023. Inclusion criteria required a clear collaboration between HRS and LRS, a primary focus on pain management, and original research either assessing baseline needs or implementing interventions aimed at improving capacity at the LRS. Of 83 studies found through the initial search, only two studies met the inclusion criteria.

One included study assessed the knowledge of pain mechanisms in nursing schools between Australia and the Philippines by seeking factual responses from participants. Another study, a collaboration between European countries, undertook a cross-sectional examination of pain education among medical students to find that pain education was viewed as a marginal and a non-essential topic.

There is interest in the education of pain, indicating an awareness-based approach to current research. However, efforts to establish global health collaborations across regions and specialties in global health are largely uncoordinated, adding to existing pervasive barriers including resource disparities, inadequate awareness and education, stigma or cultural beliefs, regulatory and ethical challenges, data accessibility and quality, and healthcare system fragmentation. The present study emphasizes the urgency for original research implementing impactful and sustainable global health frameworks of care in pain management.

A 53-year old gentleman with chronic left heel pain initially presented to Orthopaedics for left foot and heel pain. A surgical decompression of his tarsal tunnel was performed in 2019 with good relief of lateral heel pain. He subsequently developed worsening medial heel pain for which he was also seen by Rehabilitative Medicine and started on oral and topical analgesics, alongside lifestyle interventions. Extracorporeal shockwave therapy was performed but only provided temporary minor relief of pain. He was then referred to the chronic pain management clinic for consideration of further interventions in view of persistent heel pain interfering with his daily activities.

The patient was reviewed in the pain management clinic in Jan 2024 and a bedside ultrasound of the heel showed mild tibial nerve swelling with no obvious Baxter nerve impingement. He was offered a diagnostic left medial plantar nerve block, which was done in clinic and provided good pain relief. A therapeutic left medial plantar nerve steroid injection was then performed in the same setting with administration of 20mg of perineurial triamcinolone under ultrasound guidance. The patient returned to clinic a month later in view of recurrence of pain after an initial pain-free period and was keen for further intervention. He was counselled appropriately and underwent ultrasound guided left medial plantar nerve stimulation, and pulsed radiofrequency neuromodulation with injection of 50u botulinum toxin, 20mg trialcinolone and 2ml of 0.5% Bupivacaine. He was reviewed at 1 and 2weeks post-procedure, and reported improvement of his heel pain by 40-50%.

Fibromyalgia is a non-malignant chronic pain syndrome characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and a high prevalence of comorbid anxiety and depression, presenting a significant clinical burden and a complex treatment course. Due to the often-limited efficacy of current treatment options, the medical community continues to explore novel therapeutic strategies. Lidocaine is known to be a safe and effective treatment when it is administered intravenously (IV) to produce clinically efficient analgesia in patients who suffer from a variety of pain disorders, including FM.

A 66-year-old woman with a diagnosis of fibromyalgia and widespread chronic pain was referred for consideration of intravenous lidocaine therapy. She had undergone multiple pharmacological interventions with limited efficacy and demonstrated intolerance to duloxetine and pregabalin. A treatment regimen of incremental-dose lidocaine infusions was proposed, with doses ranging from 2mg/kg to 5mg/kg administered over five treatment sessions. Visual Analog Scale (VAS) scores for pain were assessed before and after each lidocaine infusion, as well as 30 days following the fifth infusion.

The patient reported subjective improvement in pain intensity from the treatment initiation to its completion, as demonstrated in Figure 1. This improvement appeared to be sustained at the one-month follow-up, with the patient experiencing continued pain relief and enhanced quality of life.

Intravenous lidocaine infusions demonstrated a favorable safety profile and efficacy in the treatment of fibromyalgia, resulting in pain improvement and enhanced quality of life.

Traditionally, the care for patient with chronic back pain has been segmented into interventional pain procedures with follow-ups between 12-16 weeks. Additionally, a Pain Management Programme provides these cohort of patients with strategies to manage their pain in daily life, focusing on psychological, physiotherapy, nursing and medical care) This project aims to: • Integrate our psychology, physiotherapy, nursing, and interventional modalities into a cohesive functional restoration service model. • Determine if additional physiotherapy and psychology input shortly after an intervention will augment the efficacy of that intervention to the patient.

Patients undergoing interventional pain procedures for chronic back pain were identified as potential participants. Selected participants were assigned to either a control group or functional restoration programme group. All patients completed a pain assessment questionnaire and the Pain Catastrophizing Scale was filled out on the same day. Participants allocated to the Functional restoration program attended hospital for a day at weeks 3 and 4 post-intervention. They met with physiotherapists, psychologists and nursing colleagues from which they were assigned homework and exercises to fulfil. At week 7 post-procedure, participants filled in the same pain assessment questionnaires and a patient satisfaction survey.

17 patients were allocated to the Functional restoration program. Data collation is currently ongoing.

The hope to demonstrate that a streamlined programme will be an efficient and feasible alternative to a PMP. It should confer benefits to patients such as reduced pain scores, enhanced psychological tools for patients to adapt to their current pain status, exercise regimens for functional restoration.

Phantom limb pain, affecting up to 80% of amputation patients, results from a complex interplay of factors including severe pain experiences, peripheral and central sensitization and altered body perception. The surgical removal of a limb disrupts afferent feedback and causes neuroplastic changes in the sensorimotor cortex. Effective management requires a multimodal approach and pain control is fundamental for an effective rehabilitation pathway.

A 26-year-old male, had a right upper limb traumatic amputation from a work accident the previous year. An active smoker but otherwise healthy, he is followed in a chronic pain clinic for phantom limb pain and is a candidate for a bionic prosthesis. Initially on pregabalin 150mg, he rated his pain as intense, with various neuropathic pain symptoms in the amputated limb, including tingling and ice-cold sensation. Examination revealed allodynia in the scar area.

His medication was increased to pregabalin 450mg and amitriptyline 10mg, with tramadol plus paracetamol as needed. Two months later, after starting prosthesis training, pain worsened and the idea of moving the lost arm was excruciating. An ultrasound-guided supraclavicular brachial plexus block was performed with 20mL of ropivacaine 0.2% and 4mg dexamethasone. His usual medication was maintained. At revaluation, he reported controlled phantom limb pain during physiotherapy, allowing an effective prosthetic training.

Proactive, multimodal management of phantom limb pain by an interdisciplinary team is essential to prevent long-term complications, improve rehabilitation, promote independence and quality of life.

Fibromyalgia, a complex chronic pain syndrome, presents significant therapeutic challenges due to its multifactorial nature and varied symptomatology. A personalized, multimodal approach is essential for effective management, considering its diverse manifestations and individual patient factors.

Patient S.F., a 28-year-old female from Algiers, diagnosed with fibromyalgia according to the 2010 ACR criteria. She experienced chronic diffuse pain for 2 years, with comorbidities including psoriasis, gastritis, and functional colopathy. Despite normal paraclinical investigations, she reported moderate neuropathic pain (DN4 score 5/10) and severe pain intensity (VAS 8/10, pain score 16/18). Treatment included pregabalin and amitriptyline, alongside non-pharmacological interventions like relaxation sessions and physiotherapy. Psychological support was provided, and mesotherapy was attempted but ineffective. At the 4-month follow-up, pain intensity reduced significantly (VAS 3/10, DN4 1/10), with improved sleep quality and mood. The patient planned marriage and showed satisfactory therapeutic compliance, reducing productivity losses at work. She had a family history of rheumatoid arthritis and moderate anxiety and depression scores (HAD). Recommendations included gentle physical exercises and educational sessions on fibromyalgia.

Significant improvements in pain intensity, sleep quality, and mood were noted during the 4-month follow-up period. The patient reported high treatment satisfaction, enhanced coping skills, and reduced functional impairment, underscoring the effectiveness of the integrated approach.

This case highlights the importance of addressing fibromyalgia through a holistic lens, integrating evidence-based interventions from various disciplines to meet the complex needs of patients. Additionally, it emphasizes the role of patient education and empowerment in fostering self-management and treatment adherence.

Neuropathy secondary to ulnar nerve entrapment is a painful condition that often persists following surgical decompression. We describe a case of a 54-year-old female experiencing neuropathic pain in her right forearm and hand following three unsuccessful surgical interventions to repair ulnar nerve. Pharmacological treatments failed to alleviate her symptoms, leading to the consideration of peripheral nerve stimulation as an alternative therapeutic approach.

Peripheral nerve stimulation of the right ulnar nerve was proposed and implemented parallel to the nerve and proximal to the lesion.

Peripheral nerve stimulation of the ulnar nerve proximal to the elbow resulted in a significant reduction in pain and improvement in disability post-implantation. The patient experienced significant pain relief and during the follow up showed a complete resolution of the symptoms, starting at four hours daily use of the neurostimulator and ending at an occasional use.

Peripheral nerve stimulation emerges as a promising intervention for refractory peripheral neuropathic pain in cases of unsuccessful surgical interventions. This case suggests that it is a promising minimally invasive technique that should be considered for treating non-operative upper extremity neuropathic pain. Its properties such as neuromodulation by altering nerve activity through targeted stimulation are evidenced in this case by a notable decrease in neurostimulator usage hours during follow-up.

Chronic neuropathic pain resulting from herpes zoster infection presents significant challenges in pain management. We present the case of a 73-year-old male referred to the chronic pain unit for management of severe neuropathic pain in the territory of the superior branches of the left superficial cervical plexus. The aim of this case report is to show a different approach to peripheral subcutaneous field stimulation lead placement and selective neurostimulation.

The patient presented chronic neuropathic pain of mean intensity of 8 Visual Analog Scale (VAS) resistant to medical therapy and pulsed radiofrequency that had previously undergone a single-shot block of the cervical superficial nerve with temporary pain relief. Peripheral subcutaneous field stimulation was proposed and accepted by the patient. Under ultrasound guidance, two subcutaneous leads were placed in the left superficial cervical plexus without complications. The two electrodes were placed parallel to each other, next to the greater auricular nerve and lesser occipital nerve, as shown in figure 1. The electrodes were tunneled for the posterior region of the left shoulder girdle. The external pulse generator was parameterized until total pain relief was achieved.

At the 1-month follow-up, the patient reported a mean pain intensity of 1-2 (VAS).

Peripheral subcutaneous field stimulation shows promise as a therapeutic option for localized chronic neuropathic pain following herpes zoster and we intend to describe the new approach with two subcutaneous leads placed parallelly.

Spontaneous Intracranial Hypotension (SIH) results from non-iatrogenic cerebrospinal fluid (CSF) leakage, causing CSF hypovolemia. Characterized by orthostatic headaches that worsen upright and relieve when lying down, SIH is diagnosed through clinical history, symptoms, and imaging showing low CSF pressure (<60 mm H2O) and leakage. Etiologies are often unknown but typically involve fragile dura mater areas, often requiring blood patches for resolution.

A 49-year-old female health professional developed severe holocranial headaches one week post- forceful, rapid back-and-forth movement of the neck, worsened in upright posture (EVN 10) and relieved when supine (EVN zero). Empirical meningitis treatment failed, and cisternography confirmed a CSF fistula. Initial treatment included rest, hydration, and analgesics: dipyrone (1g q4h), ibuprofen (600mg/day), pregabalin (up to 300mg/day), and escitalopram (10mg/day). Persistent symptoms led to hospitalization, venous hydration (2000ml/day), and a fluoroscopy-guided epidural blood patch (25ml blood at L1-L2 and L4-L5). The patient maintained EVN zero post-procedure and was discharged after 48 hours. Six months later, the patient developed kinesiophobia and catastrophizing behavior, avoiding rehabilitation and work despite continuing escitalopram. Psychological and physiotherapy support initiated after three months led to gradual improvement. One year post-accident, the patient regained autonomy and returned to work.

SIH management requires a multidisciplinary approach addressing physical and psychological aspects. Initial imaging should include contrast-enhanced MRI of the skull and spine, with myelography if needed. Predisposing factors include dural weaknesses, connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome), and hormonal influences, with women more frequently affected. Comprehensive care is crucial for optimal recovery.

Pain is a sensory and emotional experience associated with actual or potential tissue injury. Neuropathic pain results from injury or disease affecting the somatosensory system, often becoming chronic and severely impacting life quality.

A 61-year-old hypertensive male (90kg, 1.70m) presented with chronic neuropathic pain (VAS 10) in the right hand, since three years ago after blunt trauma to the right median nerve. The pain was refractory to analgesics, NSAIDs, and opioids, with allodynia in the palm and first three fingers. Thermography showed hyporadiation in the median nerve dermatome. Initial therapy with Duloxetine (60mg/day) and Pregabalin (300mg/day) provided partial relief (VAS 8). He underwent three ketamine infusions (0.3mg/kg/h) and a stellate ganglion block (0.5% lidocaine, 6ml) with temporary improvement. Intradermal botulinum toxin type A (100U) was administered, resulting in 50% pain reduction after two weeks, lasting 14 weeks. A second application provided more significant pain, allodynia, and ectopic discharge improvement.

Botulinum toxin (TxB-A) is increasingly used for pain management, beyond its muscle relaxation effects in dystonia. TxB-A reduces neurogenic inflammation and nociceptive neurotransmitter release, inhibiting Na+ channels in the nervous system. It has shown efficacy in treating migraines, post-herpetic and post-traumatic neuralgia, CRPS, and phantom pain with minimal side effects. Pain relief from TxB-A lasts 3 to 6 months, often requiring serial applications, with improved outcomes after the second or third application.

The reported incidence of posttraumatic stress disorder (PTSD) is increasing—in part,due to improved recognition, but also as a result of recent arge-scale military and civilian traumatic events in the world as Russian invasion in Ukraine.Enduring a trauma and then having to relive it through nightmares, flashbacks, and anxiety attacks is a terrifying experience.In early October 2022,an international research group conducted a survey, according to which 25.9% of respondents from Ukraine had symptoms of "probable PTSD."This case report demonstrate our successful treatment of acute symptoms of PTSD.

A 36-year-old male was the victim of an millitary conflict at Ukraine.He recived mine -blast injury of the lower extrimities.35 days he was on treatment at the hospital.He denied intensive physical pain but reported having sporadic attacks of nausea, shaking, loss of appetite, and insomnia.Twenty days post trauma, the patient complained that and he was evaluated by psychologist.The medications which was prescribed by psychologist had not provided much relief.He said that he was still experiencing insomnia and nightmares.He noted that the patient’s presentation was tearful and marked by extreme anxiety and vigilance.Based on these complaints and medical history,psychologist diagnosed PTSD.

After the SGB,the patient experienced a major reduction in anxiety.Over the next week his improved allowing a significant reduction of antianxiety medications. Сlinician Administered PTSD Scale (CAPS-5)level reduced.

Multiple CNS structures that are neuronally connected to the SNS appear to play a role in the onset and maintenance of PTSD.We report that selective blockade of the stellate ganglion relieved our patient’s symptoms of PTSD.

Post-thoracotomy pain syndrome poses a significant challenge in clinical management due to its debilitating nature. Current treatment strategies often involve multimodal approaches, including pharmacology and interventional procedures. Recently, platelet-rich plasma has emerged as a potential therapeutic option for chronic neuropathic pain, yet its efficacy in post-thoracotomy pain syndrome remains unexplored.

This prospective consecutive case series aimed to evaluate the effectiveness of autologous platelet-rich plasma in alleviating chronic post-thoracotomy pain. Ten patients with persistent thoracic post-surgical pain were recruited at Hospital Clínic de Barcelona. Platelet-rich plasma was administered via ultrasound-guided perineural intercostal injections. Pain intensity, opioid consumption, and quality of life were assessed pre-treatment and at one- and three-month follow-ups.

Platelet-rich plasma administration led to a significant reduction in pain intensity, with median Numerical Rating Scale scores decreasing from 8.5 to 3.0 at one month and 4.0 at three months post-treatment. Although opioid consumption showed a downward trend, it did not reach statistical significance. Improvements were observed in the EQ-5D-3L index and visual analogue scale scores, indicating enhanced quality of life post-treatment.

This prospective consecutive case series suggests that autologous platelet-rich plasma may offer a promising adjunctive therapy for chronic post-thoracotomy pain. However, limitations including the lack of a control group and small sample size underscore the need for further research to establish the efficacy and optimize the application of platelet-rich plasma in managing post-thoracotomy pain syndrome.

Pain management in terminally ill patients is challenging, influenced by misconceptions about opioids and a lack of education among healthcare professionals. Our aim is to describe the use of opioids in terminally ill patients from January 2019 to December 2019 in a medical training center hospital in Brazil.

A retrospective cross-sectional study analyzed 43 medical records of patients in palliative care using of opioids in 24 hours and 7 days, at the University Hospital Lauro Wanderley, João Pessoa-PB, Brazil, who died in 2019. The research followed inclusion criteria, excluding cases of emergency care and less than 24 hours of hospitalization.

The study analyzed 43 medical records. 86% of patients used opioids in the last 24 hours, mainly intravenous drugs as fentanyl (figure 1). Tramadol had the highest dosages and fentanyl the lowest (figure 2). Dipyrone was the most common adjuvant (78.4% in the last 24 hours, 76.8% in the last seven days). There was no significant difference in conversion to oral morphine between periods and the equivalent opioid load did not show a normal distribution (Shapiro-Wilk = 0,75 and 0,56, p < 0,001) (figure 3).

The underuse of opioids reveals gaps in clinical practice, influenced by social stigmas and lack of knowledge. The choice of fentanyl highlights its effectiveness, but there is a tendency to use it instead of morphine. Heterogeneity in prescribing highlights the need for clearer guidelines. The study has limitations, such as its retrospective nature and gaps in documentation, highlighting the importance of improving data collection.

The Erector Spinae Plane (ESPB) efficiency in thoracic and abdominal pain management has been well demonstrated. Since the erector spinae muscle (ESM) extends to the cervical spine, cervical ESPB holds potential addressing painful conditions of the shoulder girdle. Remarkably, cadaveric studies have found that injection at cervical levels consistently stained brachial plexus (BP) roots and dorsal rami.

A 46-years-old woman who had undergone lumpectomy and lymph node removal along with chemotherapy for left breast cancer eight years ago presented to chronic pain consultation. The patient reported severe hyperalgesia and allodynia in the trapezius region and left shoulder, particularly along the ulnar nerve pathway. Her current pain management regimen included gabapentin, tapentadol, clonazepam, escitalopram and lorazepam. After obtaining written informed consent, ultrasound-guided cervical ESPB at C6-C7 and ulnar nerve block at the mid-arm point were performed, with 14 and 6 ml of 0.2% ropivacaine, respectively, supplemented with 8 mg of intravenous dexamethasone.

At the one-month follow up appointment, the patient reported a significant improvement in shoulder pain and a complete resolution of pain along the ulnar nerve pathway, enabling a significant reduction in rescue analgesics frequency.

Cervical ESPB presents as a promising alternative in managing chronic shoulder pain compared to other interventional procedures. Its mechanism might involve the spread of local anesthetic across multiple vertebral levels within the musculofascial plane deep to the ESM, reaching C5 to C7 roots anteriorly. Despite our successful results, further investigations are needed.

67-year-old man with acute clinically severe right L5 breakthrough radiculalgia, which improves with axial loads and worsens in decubitus.In MRI a L5-S1 space synovial cyst 8 mm, originating in the right facet joint that contacts and displaces the roots of the cauda equina (Fig. 1).We perform an interventional approach to the cyst with a percutaneous right L5 - S1 zygapophyseal transarticular approach with Quincke 22Gx90 mm needle.Needle advancement is performed with tunnel vision in a 30° oblique projection until its impossible to progress the needle any deeper.As it is not possible to enter the light of the cyst, filed hydrodissection was attempted, thus it is decided to approach the cyst with a needle guide of the same diameter but 150mm in length.

The guide was progressed in lateral projection until the light of the cyst, the guide was removed and contrast placed through the needle. Once passage was seen through the contrast to the right L5 foramen, without evidence of cystic image, the needle was removed. patient sent to recovery room . After the procedure the symptoms disapeared from the radicular point of view, and in 14 months of follow-up, he remained asymptomatic.

Facet cyst can develop from arthritic facet joint, the one located intracanal and make contact with a nerve root, may produce radicular clinic 1,2.We present this case with a technique, which to the best of our knowledge, has not been described before,an interventional approach, minimally invasive saving the patient from undergoing spinal surgery. 1ShahRV,et al.SpineJ2003;3:479-88;2Wilby MJ,etal.Spine(PhilaPa1976)2009;34:2518-24;3ChazenJL,et al.ClinImaging2018;49:7-11.

50 years old, with a left fibula exceresis, immediate postoperative period the patient reported severe intense pain. Patient with diagnostic criteria of CRPS type 2, in view of the surgical history, a nerve MRI was requested which reports extensive neuropathy of the superficial peroneal branch grade 3 with areas Sunderland grade 4 with the presence of small nodular images reminiscent of continuity neuromas with involvement of the blood-neural barrier. The extension of the neuropathy is approximately 12cm. No discontinuity of the epineurium was identified. Fibrotic changes surrounding the nerve branch the most significant at the level of its passage to the subcutaneous space.

Multiple interventional treatments were performed without response, so we perform a approach of superficial peroneal nerve and pulsed radiofrequency plus a ultrasound-guided intranervous PRP infiltration, the patient reported 80% improvement of symptoms, maintained for 8 months with subsequent recurrence, we perform again the same approach without response.

Intraneural injection of PRP has been used for the treatment of compressive neuritis1, platelet activity once activated favor the release of cytoplasmic granules that promote a potential therapeutic effect to promote nerve repair 2. The exact molecular mechanism by which PRP produces nerve repair is not elucidated, multiple mechanisms have been proposed.

In our patient the symptoms reappeared, taking into account the extensive neural damage, we suppose that the failure to respond is due to progression of the damage, more studies with this technique are needed to validate this observation. 1Bejarano MC,et al.Cureus. 2023 Jul 20;15(7):e42223. 2Sánchez M,et al.ExpertOpinBiolTher. 2017Feb;17(2):197-212.

The trigeminal nerve, supplying craniofacial structures, is involved in facial pain pathologies. Pain of trigeminal origin is also projected to the territory of the greater occipital nerve. These patterns of pain referral reflect a broad overlap of cervical and trigeminal afferents. Convergent peripheral nerves integrate occipitocervical and trigeminal Ad-fiber and C-fiber inputs. Afferent-driven presynaptic inhibition can finetune nociceptive information flow. An intervention at this level could theoretically improve pain scores.

A 68 year old male patient presented with a bilateral trigeminal nevralgia refractory to treatment. He has a personal history of multiple sclerosis and trigeminal nevralgia – since 2011, for which he is presently medicated with carbamazepine 400mg bid, gabapentin 400mg qid, transdermic fentanyl 50mcg every 3 days, morphine 10mg SOS, paracetamol 1000mg bid, sertraline 50mg id, alprazolam 0,5mg id and diazepam 10mg id. He refers dysphagia and choking. Sublingual fentanyl 133 mcg and sphenopalatine ganglion block had poor results. The next step would be surgical radioablation.

In the next consultation, the patient presented with a 8/10 pain and we performed an ultrasound guided bilateral occipital nerve block with ropivacaine 2mg/ml and metilprednisolone 40mg, 1.5ml on side and the results were immediate, with reported pain scores of 0/10 and were maintained for two weeks.

Trigeminal nevralgia can be challenging to manage, leading to severe decrease of quality of life. Occipitocervical inputs can modulate pain responses originated from the trigeminal nerve. Presynaptic inhibition could explain improved pain scores in our patient and could be promising therapeutic targets in chronic pain settings.

The acceleration-deceleration energy transferred to the cervical spine during a motor vehicle collision can cause whiplash injury, which can lead to headaches in 80% of patients. Patients with persistent headaches due to whiplash have been treated with peripheral nerve stimulation (PNS), although the evidence for its effectiveness is limited.

A case report about a patient who received temporary peripheral nerve stimulation following a whiplash injury and developed neck and severe right occipital pain. The patient received SPRINT PNS System (SPR Therapeutics, Cleveland, OH, USA) implanted lead and an external pulse generator to deliver stimulation to the target nerve. The treatment lasted 8 weeks, and the percutaneous leads were then removed. Follow-up surveys were conducted 14 weeks after the implant removal.

The procedure reduced the pain score from 8/10 to 0/10. He experienced improved sleep, quality of life, and physical activities with 81-90% satisfaction.

Peripheral nerve stimulation effectively treats refractory whiplash pain, improving long-term pain relief, range of motion, quality of life, sleep, and patient satisfaction. It is a successful treatment option for chronic whiplash pain.

This study was conducted to assess the efficacy of combining transforaminal epidural steroid injection (TFESI) with caudal epidural steroid injection (CESI) versus TFESI with interlaminar epidural steroid injection (ILESI) on patient pain, anxiety, and disability status in individuals suffering from radicular pain

A cross-sectional study was conducted in the National Hospital & Medical Centre Lahore from September 2022 to September 2023. Eighty patients with low backache and radicular pain who met the inclusion criteria were enrolled. The patients were randomly divided into Group A (TFESI + CESI, n=40) and Group B (TFESI + ILESI).

The mean age of the patients in Group A was 59.4 ± 10.2 years, while in Group B, it was 57.6 ± 11.1 years. Most patients were females, accounting for 58 (72.5%) of the study population. There was a significant decrease in the mean NRS score at 2, 4, and 12 weeks compared to the baseline value in Group B (p=0.01). Similarly, the mean Hamilton Anxiety Score and Oswestry Disability Score were significantly reduced after the intervention in Group B (p=0.04, p=0.01, respectively). Comparable findings were observed in Group A, with significant decreases in the mean NRS score at 2, 4, and 12 weeks (p=0.02) and substantial reductions in the Hamilton Anxiety Score and Oswestry Disability Score (p=0.001, p=0.03, respectively).

This study found that combining CESI and TFESI with catheter offered a slightly more effective pain reduction than TFESI and ILESI after 12 weeks.

Chronic limb-threatening ischemia (CLTI), the advanced stage of lower extremity artery disease (LEAD), is associated with high mortality, limb loss, pain, and diminished health-related quality of life (HRQL). Despite advancements in endovascular treatments, significant amputation rates (12-20% within the first year post-revascularization) persist due to ongoing microvascular dysfunction that impairs blood flow and oxygen delivery. Lumbar sympathectomy (LS), a minimally invasive procedure disrupting sympathetic nerve pathways, has shown potential to reduce peripheral resistance and enhance microvascular circulation, though its role in CLTI treatment is not well understood.

Our study (approval number 4/2023/VUSCH/EK, clinicaltrials.gov NCT06111599) evaluates the efficacy of lumbar sympathetic block (LSB) in three CLTI patients by assessing thermal changes and pain levels. We focused on comparing skin areas on the legs and feet, considering their innervation by peripheral nerves, which are related to the localization of angiosomes. These areas include dermatomes innervated by the saphenous nerve (L3,4), tibial nerve branches (medial plantar nerve L4,5; lateral plantar nerve S1,2; medial calcaneal branches S1,2), sural nerve (S1,2), and superficial peroneal nerve (L4-S1), corresponding to the posterior tibial, peroneal, and anterior tibial artery angiosomes, respectively.

Post-LSB, patients showed increased limb temperatures and reduced pain, indicating improved perfusion and symptom relief.

These findings suggest that LSB could benefit CLTI patients, particularly those ineligible for endovascular procedures. Further research through a randomized controlled trial is needed to confirm LSB's therapeutic potential and explore advanced techniques like cryoablation and radiofrequency ablation for prolonged denervation effects.

Osteoarthritis (OA) is a chronic degenerative joint disease. In recent years, adipose-derived mesenchymal stem cells (AD-MSCs) have emerged as a promising treatment for regenerative medicine. The application of stem cells to degenerated joints has been shown to restore articular cartilage, alleviate pain, and improve quality of life.

This study retrospectively reviewed 86 patients with knee and hip osteoarthritis who underwent intra-articular stem cell therapy. Patients were evaluated using visual analog scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Lequesne, Short Form-36 (SF-36) scores, and radiological scores on current radiographs before and after the procedure. Additionally, adverse events were monitored during the 6-month follow-up period.

The patients' VAS scores decreased significantly from 8 at baseline to 3 and 2 at 1st and 6th months, respectively, according to the Friedman test (p < 0.001). WOMAC total score was 65, 24 in the 1st month after treatment and 18 in the 6th month after treatment. Lequesne and SF-36 scores also improved significantly from baseline to 1st and 6th months. These measurements were statistically significant (p<0.001). No adverse events were reported. Mild transient pain and swelling were noted in a few patients in the small patient group, but no major side effects occurred.

The intra-articular application significantly improved outcomes in patients and did not cause any side effects, suggesting that intra-articular stem cell application may be a promising option in the treatment of osteoarthritis. However, prospective RCTs with larger sample size and long-term follow-up are needed.

Brachiocephalic vein (BCV) cannulation in commonly done in paediatric patients and various maneuvers are used to increase its diameter. The aim of the study was to assess which maneuver increases the diameter (%) maximally: Trendelenburg position, Valsalva maneuver alone or in combination using ultrasound. The secondary objectives was to assess the change in distance between the left BCV and an ipsilateral apical pleura after these maneuvers.

120 patients less than 2 years of age planned for surgery under general anaesthesia were enrolled in this trial. The patients were randomized into 3 groups.: Group TV: Trendelenburg + Valsalva (15 tilt for 2 mins with Valsalva in last 10 seconds) , Group V: Valsalva (10 seconds) , Group T: Trendelenburg (15 tilt for 2 minutes). After giving general anaesthesia, the baseline measurements were taken followed by the various maneuvers.

There was an increase in diameter after the application of manoeuvre in all three groups. The change in the LBCV diameter after the manoeuvre was highest in Group TV 16.3% (0.087 cm) as compared to 14.03% (0.079 cm) and 10.3% (0.066 cm) in Group V and Group T. There was an increase in the distance between the LBCV and pleura after the application of manoeuvre in all three groups. The distance increase was also maximum in Group TV.

Thoracoabdominal incisions in pediatric oncology patients pose challenges for pain management, often presenting with contraindications to neuraxial anesthesia. Peripheral nerve blocks like serratus anterior plane (SAP) and external oblique intercostal (EOI) blocks may be alternatives. We aim to assess the efficacy of ipsilateral SAP and EOI catheters for postoperative pain management in pediatric patients with contraindications to neuraxial anesthesia.

Two pediatric oncology patients underwent major abdominal surgeries via thoracoabdominal incisions. Neuraxial anesthesia was contraindicated due to thrombocytopenia and underlying coagulopathy, respectively. SAP and EOI catheters were inserted preoperatively under ultrasound guidance. Analgesia was provided peri-operatively using a combination of continuous ropivacaine infusion through the catheters with IV hydromorphone patient-controlled analgesia (PCA) as a backup.

Both patients experienced effective postoperative pain management with SAP and EOI catheters. Pain scores assessed using the FLACC Scale were low throughout hospitalization. PCA was quickly weaned, and oral narcotics were unnecessary. The catheters were removed without complications, and both patients had successful postoperative courses.

SAP and EOI catheters offer effective analgesia for pediatric patients undergoing thoracoabdominal incisions when neuraxial anesthesia is contraindicated. Despite the limitation of lacking visceral analgesia, these catheters provide targeted pain relief away from the surgical field. Multimodal analgesia, including low-dose opioid PCA, complements peripheral nerve blocks for comprehensive pain management. Overall, SAP and EOI catheters represent valuable alternatives in such scenarios, ensuring optimal postoperative outcomes.

Caudal anesthesia is a frequently used anesthetic method for lower abdominal and urogenital surgery. It provides sensory and partially motor block at T10-S5 dermatomal level. In this case report, we aimed to present the anesthetic management of a pediatric patient that clear liquid came into the caudal needle during caudal anesthesia.

A boy (10-year-old-32 kg), who had planned testiculer surgery under caudal block+general anesthesia, patient have undescended testis and had no additional systemic health problem. Following anesthesia induction, LMA was inserted. Anesthesia was maintained with sevoflurane inhalation. Patient positioned lateral decubitus, surgical asepsis was applied, 22 G-3.0 cm needle was inserted through the sacral hiatus. When the needle was at the 1st. cm, the sacrococcygeal ligament was passed but clear liquid was obtained at aspiration. Liquid sample was taken and the sample was sent to evaluation. Postoperative CT scan was performed to evaluate the caudal anatomy. The sample was confirmed to be CSF. Computed tomography imaging revealed “Hypodense, consistent with a Tarlov cyst, there is an area of CSF density and the dural sac extends to the S4 level”.

The most serious complications during caudal block are total spinal anesthesia due to intrathecal injection and systemic local anesthetic toxicity due to intravascular injection. Although the use of ultrasonography has reduced these complications, it has not completely eliminated them.

It should be kept in mind that anatomical variations may occur during caudal block.Needle aspiration shouldn’t be neglected during caudal anesthesia even underwent ultrasonography guidance.

Obtaining a comprehensive history from a patient is essential to making an accurate pain assessment, diagnosis and management. In the paediatric population, collaborative history from the parents often provides valuable insight into the pain experienced by the patient. However, this may also be misleading at times.

We present the case of a 10-year-old school-going girl who was admitted for a complaint of headache following an accidental head injury. A diagnosis of severe post-concussion headache was made in view of normal findings on physical examination and investigations but a pain history reporting significant pain according to the patient’s mother. The patient’s analgesic requirement escalated quickly despite an observed improvement in function. Within a few days, she became increasingly drowsy after being on high dose gabapentin and amitriptyline. Subsequently, through tactful segregation of the patient from her mother, we were able to obtain a more reliable history from the patient herself.

The child had difficulty conveying her symptoms due to the overbearing presence of her mother, no doubt driven by concern for her child. Consequently, the severity of the patient’s pain symptoms were consistently exaggerated by her mother. In fact, effective pain control was achievable with a simpler analgesic regime. After readjusting her medications, her pain and drowsiness improved.

Overreliance on parental history can complicate pain assessment and management in children. Pain history should ideally be sought from the patients themselves whenever possible, even in the paediatric population.

Pediatric regional anaesthesia lacks evidence-based clinical practice, prompting ESRA and ASRA to provide practice advisories. However, selecting the safest strategy for complex cases remains challenging.

Description of the intraoperative analgesic-anaesthetic management of a multiple limb amputation.

A 13-year-old, BMI 12.7, 29kg patient diagnosed with acral necrosis post-septic shock underwent minor amputations in both upper extremities, with a more aggressive approach on the right side, and transmetatarsal and infracondylar amputations on the left foot and right lower extremity. Combined anaesthesia was performed and included intravenous dexamethasone, dexketoprofen and paracetamol. An epidural catheter was placed at 8 hours, followed by fractionated administration of ropivacaine 12mg. At 11 hours, a left axillary block was performed with ropivacaine 20mg and dexamethasone. Subsequently, at 13 hours, a right supraclavicular catheter was placed, administering ropivacaine 20mg and dexamethasone. Precautions were taken to avoid systemic toxicity, such as dose fractionation and staggered blocks as different surgical areas were addressed. However, the total doses exceeded the theoretical toxic dose. Another approach involves reducing the local anesthetic concentration. Recommendations are available for continuous infusions of a single block, not two as presented in this case. Two infusions were maintained at the safety limit established for 24 hours, but this limit does not consider simultaneous blocks. Subsequently, only the epidural infusion was continued.

Diligence is crucial to avoid iatrogenic effects with single-injection multiple blocks in paediatrics. Continuous multiple blocks need further evidence on cumulative dose safety. Dose fractionation and staggered blocks help prevent peak plasma levels of local anaesthetic.

Pain control after thoracotomy is critical in preventing pulmonary morbidity. There has been growing interest in non-opioid/non-neuraxial analgesic techniques, providing effective pain relief with minimal complications, such as the erector spinae plane (ESP) block. Our report details application of a continuous ESP block in thoracic Ewing’s sarcoma resection.

An otherwise healthy 5-year-old underwent thoracotomy for extra-osseous Ewing’s sarcoma and 8th rib resection. General anesthesia with continuous ESP block at T7 level was chosen for intraoperative management. This involved a 0.5 mL/kg 0.2%-ropivacaine bolus through the ESP catheter before incision, followed by a 0.2 mL/kg/h infusion, that continued postoperatively. Postoperative analgesia included paracetamol and ketorolac, with rescue ESP bolus and intravenous morphine. The intraoperative period was uneventful. The child was extubated and transferred to intermediate care. Following a 48-hour stay, he transferred to the infirmary. Perineural catheter removal occurred after chest tube removal (6th day). Throughout hospitalization, the patient maintained satisfactory pain control, reporting maximum pain of 4/10 on the first day. Only two boluses of intravenous morphine were required during the entire hospitalization.

Historically, epidurals have been the cornerstone of post-thoracotomy analgesia. The ESP is an increasingly recognized alternative. Its superficial depth and distance from critical structures make it particularly appealing in neonates and infants, while also minimizing opioids. There remains a paucity of regional anesthesia data in pediatric thoracic surgery. Adequate spread and analgesia have been reported with a 0.3-0.5 ml/kg volume. The optimal local anesthetic dose for ESP block remains however uncertain and further research is needed.

Medulloblastomas are one of the most common malignant brain tumours in the paediatric population. Originating from the cerebellum, they have the potential to spread to other areas of the central nervous system, and can be very aggressive. Symptoms can be particularly debilitating in the terminal period, with refractory headaches, nausea and vomiting, and altered mental status that adversely affect the patient's quality of life.

We present the case of a 5-year-old boy with terminal medulloblastoma who was referred to the paediatric pain team for symptom relief. He had undergone surgical resection followed by adjuvant chemoradiotherapy prior to this but experienced an eventual relapse of the disease. The oncological team had assessed his disease to be terminal with a palliative intent of treatment. The main symptom that was causing him significant distress was severe headaches throughout the day that was refractory to conventional treatment modalities.

He was already on high doses of multiple analgesia, including morphine, ketamine and clonidine. However the intensity of his headaches persisted while the side-effects of these medications were becoming increasing pronounced with drowsiness, nausea and vomiting. As a result of this, he was either very drowsy or in severe pain most of the time, which limited his function and quality of life. After a multi-disciplinary discussion with the palliative team, a tailored analgesia plan was introduced which included opioid rotations and methadone.

Terminal medulloblastoma can be particularly debilitating. A comprehensive multi-modal analgesia plan should aim to limit adverse effects of drugs to maximise quality of life.

Osteosarcoma is a primary malignant bone tumor that represents 3 to 6% of all childhood cancers, severe refractory pain is a symptom with a frequency of up to 50%. Continous radiofrequency technique aims to increase local temperature with high frequency waves, through vibration of the surrounding particles, while pulsed radiofrequency has a neuromodulatory effect in the transmission of the pain stimuli.

5-year-old male, with blunt trauma 5 months prior to the onset of symptoms, presenting with severe chronic right knee pain, with lower limb MRI with a space-occupying lesion, biopsy showed conventional high-grade osteosarcoma of chondroblastic and osteoblastic pattern of the right distal femur, with refractory pain to pharmacological management.

In prone position, with radiographic guidance the vertebral bodies L4-L5 were located, we proceded to locate right foramina and advanced a radiofrequency needle with active tip of 10mm to the dorsal root ganglion of L3-L4 and L4-L5, sensitive tests were performed with 50Hz for 0.3V and then motor test with 2Hz by 1V confirming the stimulation of the dorsal root ganglion with distribution along the area of pain, we proceeded to infuse analgesic mixture and then pulsed radiofrequency was performed at 42°C for 5minutes per level, the procedure ended without complications.

Despite the limitations in scientific evidence and experience, interventions in pediatrics are generally performed with scarce evidence and based on experience in adults. Radiofrequency of dorsal root ganglion is described as a safe and low-risk procedure, with high benefits in the control of low back and lower limb pain.

Erector spinae plane block (ESPB) has been increasingly used in surgical pain management for many procedures, including in pediatric patients. ESPB's mechanism of action is still not completely understood. The target location for local anesthetic administration, timing, and pharmacological approach varies in the literature. Evidence of the effectiveness of ESPB is controversial and limited, especially in pediatrics, but recent reports show a promising regional technique for perioperative pain control in these patients.

We report a case of a 4-month-old girl, ASA-PS II, weighing 6,2Kg, scheduled for an open pyeloplasty with ureteral stent substitution for left pyelo-ureteral junction syndrome.

We decided to perform a combined anesthesia, with ESPB for perioperative analgesia. After general anesthesia induction, a single-shot left ESPB at T9 level was performed under ultrasonography guidance. A total of 0,5 mL/Kg of ropivacaine 0.2% was injected. Anesthesia was maintained with sevoflurane. A multimodal analgesia regimen also included intravenous ketamine (0,3mg/kg), acetaminophen (10mg/kg) and ketorolac (0,5mg/kg). Hemodynamic stability was maintained throughout the procedure (120min). The postoperative pain FLACC score was 0/10 in PACU and over the next 48 hours of hospitalization. No rescue analgesia was need during hospital stay, namely opioids.

A continuous ESPB for open pyeloplasty in an infant has been reported. We present a case of successful single-shot ESPB analgesia, suggesting it can be a part of an effective multimodal analgesia regimen for the management of acute postoperative pain after open pyeloplasty in pediatric patients with opioid sparing.

In recent years, the ultrasound-guided costoclavicular brachial plexus block (CCB) has emerged as a novel approach for paediatric anaesthesia, presenting a potentially lower risk profile and effective regional anaesthesia technique. The costoclavicular space is situated between the posterior surface of the middle-third of the clavicle and the anterior chest wall.

This review synthesises existing literature, studies, and clinical cases that focus on the costoclavicular approach. The focus was on paediatric outcomes, evaluating block success rates, analgesic efficacy, incidence of complications, and postoperative pain scores in comparison to traditional techniques like lateral sagittal and supraclavicular blocks.

The findings indicate that CCB provides a success rate comparable to traditional methods but with notable advantages including shorter block performance times and faster onset of action. Fewer complications were observed, such as reduced incidents of hemidiaphragm paralysis. The cords of the brachial plexus are superficially positioned within the costoclavicular space and maintain a consistent relation to each other and the axillary artery, facilitating enhanced ultrasound imaging and improved visibility of the needle. These anatomical characteristics have likely played a significant role in the successful implementation of the block. In the case of younger children, to address anatomical hurdles such as the coracoid process obstructing needle entry, it is advisable to employ alternative techniques for needle insertion, such as the medial to lateral approach, ensuring both safe and effective pain management.

CCB emerges as a valuable technique for paediatric upper extremity surgeries, providing a safer and effective alternative with shorter procedural times and minimal complications.

Tracheoesophageal fistula (TEF) is a congenital anomaly often observed with other significant developmental defects, such as those characterised by the VACTERL association, which includes vertebral defects, anal atresia, cardiac defects, renal anomalies, and limb deformities. Management of Double Outlet Right Ventricle (DORV) adds complexity, requiring a detailed understanding of haemodynamics influenced by the alignment of major arteries, connections between ventricles, and obstructions in the outflow tract. This case report examines the anaesthetic management of a 2-day-old, 32-week preterm female neonate with DORV and pulmonary stenosis (PS), who required surgical intervention for TEF.

Initial management included stabilisation on nasal CPAP followed by diagnostic assessments confirming DORV and TEF. The anaesthetic approach was tailored to maintain systemic vascular resistance (SVR) and minimise pulmonary vascular resistance (PVR), essential for preventing cyanotic spells. IV ketamine was selected over inhalational agents to expedite induction and to maintain SVR. In response to intraoperative hypotension episodes, volume and SVR were increased using alpha agonists such as phenylephrine.

Surgical correction of TEF was achieved through meticulous anaesthetic management, including maintaining euvolaemia and air bubbles hygiene. Monitoring and adjusting perioperative conditions were crucial to prevent hypoxia, hypercapnia, and acidosis, thereby managing PVR and avoiding cyanotic spells.

This case underscores the intricate anaesthetic strategies required in managing neonate with DORV and TEF, emphasising the importance of understanding applied physiology and pharmacology. Effective management involves a careful balance of SVR and PVR, preventing intraoperative complications, and ensuring stable haemodynamics throughout the surgical procedure.

While the overall organization of pediatric anesthesia is similar to that of adults, there are some unique aspects related specifically to the physiological, psychological, and anatomical variations. In children under three years old, morbidity associated with anesthesia is still significant, and it is higher in infants under one year old. We can design a suitable preventive approach and gain a better understanding of the risk factors unique to children by conducting surveys on the morbidity and mortality of pediatric anesthesia. We conducted our study in this setting to assess our procedures.

prospective observational study conducted in the operating room for pediatric surgery. Every incidence and negative consequence that happened throughout the study period was gathered.

Males made up 54.8% of the sample throughout this study period, while females made up 45.2%. The majority of patients (ASA1 78%) were in good health. Assistants to anesthetists performed 83% of the anesthetic operations. We have 3,15% of adverse occurrences on file. In our analysis, cardiovascular events and accidents made up the majority (16.8%). No deaths attributed to anesthesia are noted

A large-scale, systematic survey of life-threatening anaesthesia situations could cover the whole range of potential risks.

Regional anesthesia has gained increasing importance in pediatric surgery due to its efficacy in providing perioperative pain relief with fewer systemic effects. Caudal epidural anesthesia is a safe and effective technique, reducing intraoperative anesthetic requirements and postoperative respiratory depression, especially in vulnerable neonates. Ultrasound can improve its performance by aiding in identifying anatomical variations, localizing the dural sac, and reducing the incidence of complications.

We present a case of a two-day-old neonate undergoing surgical correction of jejunal atresia under combined general-epidural anesthesia. We conducted a rapid sequence induction with fentanyl, propofol and rocuronium and we used videolaryngoscopy for intubation. Afterwards, the patient was positioned in lateral decubitus with hips and knees flexed. After a failed hematic puncture through anatomical references, ultrasound-guided single-shot caudal epidural blockade was performed, using a linear transducer, with injection of 1.25mL/kg (Armitage formula) of ropivacaine 0.2% to achieve a thoracic epidural block level. The procedure was successful, with precise needle placement and adequate local anesthetic spread observed under real-time ultrasonography.

Effective perioperative pain relief was achieved, with stable hemodynamics observed throughout the procedure. Postoperatively, the neonate was transferred to the neonatal intensive care unit and extubated 11 hours later.

Ultrasound-guided caudal epidural blockade is a safe and effective method for perioperative pain relief in neonates, often enabling earlier extubation. Pediatric anesthesiologists should be proficient in sonographic neuraxial and dural sac anatomy, particularly in neonates, to safely perform this block, especially in cases of aberrant anatomy or to mitigate potential technique-related complications.

Small bowel atresia is a congenital condition requiring prompt surgical intervention. Effective pain management in neonatal surgery is critical yet challenging. Opioid use can delay spontaneous breathing and recovery of peristalsis in infants. This study aims to evaluate the efficacy and safety of peridural catheter anesthesia in a neonatal patient undergoing surgical treatment for small bowel atresia.

A full-term newborn diagnosed with small bowel atresia and a perimembranous VSD with a significant left-to-right shunt was scheduled for surgical correction. A peridural catheter was placed at the caudal interspace under ultrasound navigation. General anesthesia was established with Propofol and Suxamethonium, and hemodynamics were maintained using Dopamine at 5 mcg/kg/min. After intubation, the catheter was inserted from the caudal space to the thoracic level under ultrasound guidance using a 20G Tuohy needle. Anesthesia was maintained with Sevoflurane and a continuous infusion of Ropivacaine 0.1% at 0.6 ml/h (0.2 mg/kg/h)

The peridural catheter provided adequate analgesia throughout the 5-hour surgical procedure. Hemodynamic parameters remained stable, with no significant intraoperative fluctuations in blood pressure or heart rate. The patient was extubated successfully in the OR and transferred to the NICU for further monitoring and care. Postoperatively, the newborn exhibited excellent pain control with no need for additional opioids, except NSAIDs. No immediate or delayed complications related to the peridural catheter were observed.

The use of a peridural catheter in a neonatal patient undergoing surgery was effective and safe, facilitating excellent pain management and stable intraoperative conditions, contributing to a favorable surgical outcome.

Pediatric anesthesia holds many challenges. Pediatric regional anesthesia is even more demanding. We emphasize on developing relevant guidelines and apply them in everyday practice to provide adequate, safe regional anesthesia in pediatrics. Protocols include performing guidelines, intra- and postoperative evaluation and parent questionnaire.

Our center, as the biggest pediatric emergency center in the country, developed pediatric peripheral nerve blocks guidelines. The experience gained in variety of pediatric trauma and orthopedics, led to the need of pediatric regional anesthesia procedure unification. Preoperative guideline includes patients’ personal data, ASA, diagnosis, oral premedication. Intraoperatively, we record intervention, patients’ vital signs, induction, maintainance, emerge of anesthesia, type, time, onset of peripheral nerve block, opioid consumption, local anesthetics, complications. Postoperative analgesia is evaluated via VAS (8y-18y) and BOPS (1y-7y). Children under 1year are rarely subject to orthopedic surgery but if so, we recommend general anesthesia plus regional. Postoperative evaluation is estimated during the first 2days. We developed and applied a questionnaire, handed both to parent and child, in order to estimate their personal satisfaction, feeling and perception.

Essential part of anesthesiologists’ work is patient analgesia and satisfaction. This might be troubled in pediatrics, taking in mind their age and level of communication. We found better results after introducing strict pathways for managing, performing and evaluating peripheral nerve blocks in pediatrics.

Pain relief in children is of crucial importance. Successful peripheral nerve blocks in pediatrics require validated guidelines, strict protocol and close monitoring. We encourage parents’ involvement via questionnaire.

Osteogenesis imperfecta (OI) is a rare genetic disorder affecting connective tissue, particularly characterized by fragile bones due to a defect in type I collagen production. Challenges in airway management, positioning, increased bleeding tendency, and a high risk of malignant hyperthermia (MH) complicate anesthesia management. In this study, we aimed to retrospectively examine our experience in terms of anesthesia in pediatric patients diagnosed with OI operated in the orthopedic clinic of our university hospital.

We retrospectively reviewed files of patients with OI who underwent orthopedic surgery at our hospital between 2011 and 2022. We screened for airway management issues, intravenous access difficulties, surgical blood loss, peripheral nerve blockade/neuraxial techniques, perioperative fracture, and intraoperative peak temperature.

In our study, 40 patients with OI and 101 orthopedic operations were evaluated. Difficult airway was encountered in 1/101 (1%) and perioperative fracture in 1/101 (1%) of the cases. Neuraxial anesthesia was attempted in 32/101 cases with a success rate of 87%. All peripheral nerve block attempts (16/101 cases) were successful. Difficult intravenous catheter placement was noted in 3/101 (3%) of cases. An estimated blood loss of more than 10% of the estimated blood volume was considered significant and occurred in 17/101 (17%) cases.

Although patients with osteogenesis imperfecta are rare, the need for orthopedic surgery frequently requires anesthesia. OI is a serious disease associated with multiple complications and it is necessary to determine the severity of the disease, perform a complete preoperative evaluation and develop an appropriate, individualized anesthesia management plan for patients requiring surgery.

The axillary brachial plexus block is a well established peripheral nerve block and analgesic method even in the pediatric population. We try to examine its efficacy under procedural sedation, with the patient breathing spontaneously.

We retrospectively examined the data of 12 patients treated surgically for distal humeral fractures under procedural sedation and axillary plexus block. All patients rigorously followed NPO guidelines, and none of them had a history of vomiting or GERB. Two patients had a history of well controlled asthma, and one had a recent upper respiratory infection. The patients, aged 3 to 10 years old, were all preoxygenated, premedicated with atropine and received Propofol (2mg/kg) and Fentanyl (1,25-1,8mcg/kg) on induction. Adequate spontaneous breathing was confirmed and a continuous propofol infusion was maintained at 6-10mg/kg/h. An US-guided axillary brachial plexus block was performed using 1% Lidocaine (2-2,67mg/kg) and 0,5% Levobupivacaine (1,5-1,8mg/kg).

Intraoperatively analgesia was absolutely satisfactory, all patients maintained hemodynamic stability, breathing spontaneously with O2 support via mask (2L/min), without the need for additional analgesics or sedation. No respiratory complications were noted, and awakening upon surgery completion was uneventful.

With the intraoperative and postoperative analgesic effects of the axillary plexus block being well established, our experience suggests that the block in combination with procedural sedation is a safe and effective method, potentially beneficial for patients at increased risk of complications after intubation or use of neuromuscular blockers. Rigorous attention must be directed towards determining the risk of regurgitation and aspiration.

TAP block is a well established peripheral nerve block in the adult as well as pediatric population, with an increasing number of reports of its successful use in neonates. However, its use in extremely low birth weight (ELBW) neonates is still somewhat unknown.

A premature neonate born at GW 33, now 44 days old and weighing only 900g, presented for ileostomy necessitated by intestinal hypomotility. Medical history was significant for coarctation of the aorta, with significant differences in arterial tension between the upper and lower extremities. After placement of two peripheral venous lines and an arterial line induction was performed with Thiopental, Rocuronium. The patient was intubated and anesthesia was maintained with Sevoflurane. We performed preoperatively an US-guided right-sided subcostal TAP block, using 0,2ml of 2% Lidocaine and 1ml of 0,1% Levobupivacaine.

For the entirety of the surgery the patient maintained hemodynamic and respiratory stability, without the need for opioids, repeat rocuronium, or vasoactive/inotropic support. At the end of the surgery the patient was successfully extubated and transported to the NICU, without the need for rescue analgesia in the following 24h.

This case highlights the importance of regional anesthesia and its effective application even in ELBW neonates. To our knowledge there are no recorded cases of TAP block in patients of lower weight. Additionally, opioid free anesthesia enables quicker establishment of spontaneous breathing, superior ventilatory mechanics, and ultimately sooner extubation.

We present the case of successful analgesia with infraclavicular peripheric nerve block in a 9-year-old female patient with Osteogenesis Imperfecta and Autistic Spectrum Disorder who underwent surgery for right elbow avulsion fraction.

Before the procedure, the patient was premedicated with a 5 mg/kg ketamine intramuscular injection. After an adequate sedation level was achieved she received general anesthesia with sevoflurane inhalation induction and a laryngeal mask was placed. Because of abnormalities in connective tissue in these patients, there may be intravenous catheter placement challenges and difficulties performing neuraxial and peripheral nerve blocks. We performed an ultrasound-guided infraclavicular block using the costoclavicular approach. Synchronos to ultrasound a peripheral nerve stimulator was used to confirm the right placement of the needle and a single injection of 20 ml of 0.25% bupivacaine was made.

No complications were seen during and after the procedure. The patient was calm at the end of the operative period with an Aldrete score of 10 and Richmond Agitation and sedation scale of -1. She was discharged home uneventfully 6 hours after the operation and described little to no pain during her check-up one day after the operation.

Regional anesthesia management in pediatric patients with Osteogenesis Imperfecta and Autistic Spectrum Disorder can be challenging but with ultrasound-guided peripheric blocks the risk of complications and the postoperative pain incidence can be decreased. We think our case can be a contribution to literature because there are no established guidelines regarding regional anesthesia in the pediatric population.

Patients with hip fractures are one of the vulnerable groups for developing severe COVID-19. This study aims to assess the influence of COVID-19 infection on hip fracture surgery using data from the Korean National Health Insurance System.

This retrospective study utilized data from Korean NHIS. We included patients admitted with operation codes specific to hip fracture between January 1, 2020, and December 31, 2021. We classified patients into a COVID (+) group with a diagnosis code (U071) 30 days around surgery and a COVID (-) group without the code in the same period. The primary outcome was 30-day mortality. Secondary outcomes were pulmonary complications, ICU admission, cardiac arrest, myocardial infarction, other thromboembolic events, surgical site infection, sepsis, acute renal failure, and hepatic failure.

Among 92,599 patients, 200 had a COVID-19 diagnosis code, while 86,284 did not. After 1:4 propensity score matching (PSM) by age, sex, Charlson Comorbidity Index, American Society of Anesthesiologists Physical status more than 3, total 995 patients were included in each group. 30-day mortality showed no significant differences between the two groups both before and after PSM. The COVID (+) group demonstrated significantly elevated rates of pneumonia. Hospital length of stay and admission costs were also significantly longer and higher, respectively. Comparing anesthetic method, there was no differences were observed in mortality and postoperative complications based on general and regional anesthesia.

COVID-19 infection is associated with increased rates of postoperative pneumonia, longer hospital stays, and increased admission costs, in patients who underwent hip fracture surgery.

LEAP (Leicester Enhanced Arthroplasty Pathway) was initiated in accordance with the GIRFT (Getting It Right First Time - NHS improvement programme) standards aiming to expedite the recovery from elective hip and knee arthroplasty without compromising safety.

The LEAP provides a perioperative care standardised pathway for patients undergoing elective hip and knee replacements. There are certain steps to be followed in the preoperative period which includes optimization of co-morbidities and careful patient selection given a vast number of our patients are in the ASA3 category. Intra operative measures are aimed at minimizing post operative side effects and promoting rapid early mobilization. The anaesthetic itself involves an opioid-free spinal using either heavy 2% prilocaine, low-dose 0.5% heavy bupivacaine or 0.5% levobupivacaine depending on the expected duration of surgery. Multimodal analgesia comprises of intraoperative IV Paracetamol, PR Diclofenac or IV Parecoxib and high dose Dexamethasone (9.9-13.2mg) administration unless contraindicated. The only nerve block performed is an ultrasound-guided adductor canal block for all knee replacements. Post-operatively, patients receive regular Paracetamol, Naproxen, Codeine Phosphate and Oramorph as required. Nefopam is prescribed for patients who are intolerant to NSAIDS or opiates.

Since the introduction of LEAP, there has been a significant reduction in the length of stay following elective primary hip and knee arthroplasty surgery (Image 1, 2,3).

A multidisciplinary approach incorporating simple yet effective measures has contributed to a significant reduction in the length of stay for patients undergoing hip and knee arthroplasty surgery.

Some physicians recommend cold therapy or local anesthetic spray to reduce pain caused by drain removal and other surgical procedures. We aimed to test the effectiveness of lidocaine spray and ice application to reduce pain associated with drain removal.

For this prospective randomized controlled trial, patients were divided into three groups by computer-generated block of six randomization. In the control group, drains were removed by the standard process. In the lidocaine group, 6 puffs of 10% lidocaine spray were applied from 5 centimeters away to the skin around the drain 5 minutes prior to removal. In the ice group, an ice pack was applied to cover the skin around the drain for 5 minutes before drain removal. Pain intensity was recorded via visual analog scale at the time of removing the drain and 10 minutes after drain removal. The Kruskal-Wallis test was used to determine the statistical significance.

A total of 156 patients were divided equally into three separate groups. Visual analog scales revealed that immediately after drain removal pain intensity was significantly lower in the ice group compared to the control group and the lidocaine group (2.17 ± 0.87 vs 3.76 ± 0.92 vs 3.5± 0.89, P-value < 0.001). Ten minutes after drain removal there was also statistically significant difference in pain intensity between the three groups (0.11 ± 0.32 vs 0.40 ± 0.53 vs 0.53 ± 0.54, P-value < 0.001).

Ice application prior to intraabdominal drain removal is an effective non-pharmacologic intervention to reduce the associated pain.

Effective communication during patient handover in the Post Anesthesia Care Unit (PACU) is vital to ensure patient safety and high quality perioperative care. We initially examined the handover to nurse process at University Hospital Limerick's PACU which showed an average of 57% compliance to a standardized checklist, incorporating the SBAR (Situation, Background, Assessment, and Recommendation) format. Our initial data collection highlighted significant gaps in conveying critical information such as ASA grade, flushed IV line and contact details.

Educational sessions and posted documents in PACU were implemented to address gaps in previous SBAR handovers.We then employed the same standardized checklist to evaluate compliance following the intervention. The data collection was conducted by PACU nurses for all surgical procedures between February 12 to March 4 2024. Descriptive statistical methods were utilised for data analysis.

This audit revealed variable compliance rates across different parameters. The reported compliance rates were 86% for name, 77% for age, 82% for operation/operation name, 52% for theater number, and 77% for technique. The compliance rates for ASA grade, allergies, and co￾morbidities were 48%, 89%, and 86%, respectively. Furthermore, the compliance rates for intra-operative issues, analgesia, antiemetic, antibiotic, IV fluid, postoperative analgesia and antiemetic, investigation, line flushed, and concerns ranged from 52% to 98%. The reported contact details for queries and discharge had compliance rates of 64% and 52%, respectively. On average compliance was 72.5%.

This audit identified critical areas that require attention. There was a clear improvement in compliance after the implementation of educational posters and sessions.

Effective documentation of regional anaesthetic catheters is crucial for patient safety and continuity of care. At St George's Hospital, London, the gold standard for documentation is a dedicated template on iClip (our main patient administration system). However, catheter information is often recorded in various forms, including anaesthetic charts, free text documents, procedure notes, ED records, and sometimes not documented at all. This study aims to assess the impact of interventions designed to improve the consistency and accuracy of regional anaesthetic catheter documentation by encouraging the use of the standardized template.

An audit was conducted comparing documentation practices over a three-month period in two consecutive years, from January to March of both 2023 and 2024. Interventions included attempts to reposition the template within the hospital’s documentation system to increase its visibility and ease of use. Efforts to engage with system administrators and clinical staff were made to facilitate these changes.

The audit showed that the use of the template for regional catheter insertions remained consistent, being used in 47% of cases in 2023 and 50% in 2024. However, non-standard documentation formats continue to be prevalent, and there are still instances of missing documentation across both years.

Despite efforts to improve the placement and accessibility of the documentation template on the iClip system, there were multiple hurdles when engaging with system management. The persistence of suboptimal documentation practices indicates a need for further strategies to instigate rapid changes to integrated NHS computer systems.

Eye injuries, such as corneal abrasions, are easily preventable and recognized complications of general anesthesia (GA). This audit investigates the effectiveness of eye protection measures used during GA at University Hospital of North Midlands, focusing on the incidence of postoperative eye symptoms and how it was managed.

Data were collected from 51 GA cases between April 25, 2024, and May 15, 2024, at County and Royal Stoke Hospitals. The audit assessed the type of eye protection used, patient demographics, surgical factors, and incidence of postoperative eye symptoms.

Out of 51 patients, 7 (14%) reported postoperative eye symptoms, including redness (5), blurring (5), pain (1), temporary loss of vision (1), and photophobia (1). Most symptoms resolved spontaneously within 15 minutes. Patients aged 30-50 reported the highest incidence of symptoms, with no significant gender difference. Eye tape alone was the most common protection method used (42 out of 50 patients).

While our use of eye protection has been largely effective, opportunities exist to further reduce the incidence of postoperative eye symptoms. Effective eye protection is crucial to prevent corneal abrasions during GA. Recommendations include improving the application of eye protection, ensuring proper lid closure, and instituting a protocol for immediate escalation if symptoms fail to resolve sponataneously.

Right heart catheterization is a fundamental tool for the diagnosis, management and prognosis of pulmonary hypertension, as well as necessary in the prior evaluation of receptors for heart transplantation. The main aim is to determine if therapeutic anticoagulation represents a risk factor for the development of bleeding complications secondary to this technique in a third-level hospital.

The study design is an observational retrospective study, collecting data from patients undergoing a right heart catheterization between 2017 and 2020. A non-random sampling of consecutive cases is carried out for the study, obtaining a sample made up of 309 subjects with a confidence level of 95% and a margin of error of 5%. All patients gave their signed written consent. Statistical analysis of the collected data was carried out using the statistical package R version 4.1.

The incidence of intraprocedural complications was 5.57% and postprocedural was 1.97%, being slightly higher in relative terms in the group of patients without anticoagulant treatment (5.71% and 2.86%, respectively). However, there were not found significative statiscally differences, obtaining a p-value of 0.9215 for intraprocedural complications and 0.3062 for complications which took place after the catheterization. These complications are, to the greatest extent, operator-dependent, a consequence of technical errors attributable to the procedure itself rather than to other underlying factors.

The anticoagulant treatment do not represent a risk factor for the development of bleeding complications in patients who undergo a right heart catheterization.

Artificial Intelligence (AI) is being integrated into anaesthesiology to enhance patient safety, improve efficiency, and streamline various aspects of practice. This study aims to evaluate whether AI-generated images reflect the demographic, racial and ethnic diversity observed in the anaesthesia workforce and to identify inherent social biases in these images. Role models are essential for inspiring leadership ambitions and empowering younger generations. The medical field struggles with representation of women and minorities.

This post-hoc study compares real-world ESRA gender membership data to AI-generated images of regional anaesthesiologists. The initial cross-sectional analysis was conducted from January to February 2024, where three independent reviewers assessed and categorized each image based on gender (m/f).

According to 2023 ESRA gender membership data, 50% of members identified as male, while the other 50% identified as another gender/ chose not to disclose their gender. However, images generated by ChatGPT DALL-E 2 and Midjourney showed regional anesthesiologists as male in 97% and 99% of cases, respectively, indicating a significant discrepancy (P<0.001).

Current AI text-to-image models exhibit a gender bias in the depiction of regional anesthesia (RA), misrepresenting the actual gender distribution in the field. This bias could perpetuate skewed perceptions of gender roles in RA. The findings emphasize the necessity for changes in AI training datasets and greater support for minority RA role models. More broadly, fostering inclusive mentorship and leadership, reducing barriers for institutional representation, and implementing gender equality policies can help recognize and nurture talent regardless of gender.

Continuous fasciculation, when occurring without weakness, is referred to as benign fasciculation. Although generally considered non-threatening, cases that persist can significantly impact an individual's quality of life.

This discussion presents the situation of a 36-year-old male patient who experienced unyielding twitching localized to his left sole for a duration of two years. His medical history was devoid of any notable neuromuscular diseases, and results from electromyography (EMG) testing were within normal parameters. However, nerve conduction studies highlighted an increase in nerve conduction velocity specifically in the lateral segment of the left peroneal nerve and the left tibial nerve. Attempts at pharmacological intervention did not yield any improvement in his condition. While a nerve block targeting the left tibial nerve managed to reduce the severity of the twitching, it failed to decrease its frequency or provide a lasting solution.

In search of a more effective treatment, botulinum toxin was administered via ultrasound guidance into the flexor hallucis and digitorum longus muscles. This approach resulted in a marked reduction in both the frequency and severity of the twitching, enabling the patient to resume his daily activities and achieve restful sleep without experiencing any adverse effects.

Through this case, the efficacy of botulinum toxin injections as a treatment for intractable twitching is underscored, offering valuable insights into potential therapeutic strategies for similar clinical presentations.

Polio, or poliomyelitis, is a disabling and life-threatening disease caused by the poliovirus. An important consideration in the anesthetic management of patients with PPS is whether regional anesthesia is safe. Many anesthesiologists are hesitant to use regional anesthesia in patients with preexisting neuromuscular deficits, because of the concern of exacerbating existing disease or difficulty evaluating complications.

We present a case of right shoulder arthroscope for rotator cuff muscles repair under regional anesthesia combined with general anesthesia in semi-sitting position for 47-year-old male patient with poliomyelitis, ASA III, smoker, weight 117.5 kg, height 146 cm, BMI 53. The anesthesia plan for his shoulder surgery is ultrasound guided right interscalene block combined with general anesthesia without using muscle relaxants. Ultrasound guided right interscalene block C5-6 root level while patient awake on his lateral position without any complications. The local anesthesia used for interscalene block is Bupivacaine 0.25% and 2% lidocaine of total 7 ml were injected.

Ultimately, the decision to use general or regional anesthesia should be made on an individual patient basis weighing the risks and benefits. If a spinal anesthetic is selected, a medication with a long history of safety, such as hyperbaric bupivacaine, should be used.

Our conclusion is that post-polio patients may display altered sensitivity to any of the medications commonly used for regional and general anesthesia. Once aware of these considerations, anesthesiologists are better prepared to provide safe care, not only to patients with PPS, but to any patient with a history of poliomyelitis.

anaesthesiologists who manage trauma are frequently required to provide timely anaesthesia for patients undergoing surgical repair of hip fractures. Morbidity and mortality rise sharply if surgery is delayed for more than 48 hours, with some societies recommending surgery within 36 hours. Correctable arrhythmias with a ventricular rate over 120 beats per minutes are considered a reasonable a reasonable indication to postpone surgery. The degree of delay is undefined, but can be 24 hours or more. We present two cases of new onset fast atrial fibrillation managed in the theatre complex, resulting in minimisation of delay before surgery.

Both patients presented to our emergency department with hip fractures following witnessed mechanical falls at home. Admission ECGs demonstrated normal sinus rhythm. Ward reviews by orthogeriatric and anaesthesia teams did not reveal any new cardiac issues. On application of monitors in theatre, both patients had rapid irregular rythyms without discrete P waves. Atrial fibrillation was confirmed with 12 lead ECGs. Both patients were treated with IV lidocaine, Magnesium, fluids, and Amiodarone and monitored in the theatre complex while their condition improved.

Both patients conditions improved to the point where it was felt reasonable to proceed with surgery. Neither patient suffered further complications, and both survived to discharge and follow up with orthopaedics.

It is reasonable to consider managing new onset fast atrial fibrillation discovered in theatre. This strategy may have benefits to patients through reduced waiting times to surgical repair, and to the healthcare system through efficient use of skills and resources available.

The term ventricular storm (VS) is defined as the occurrence of 2 or more separate episodes of ventricular tachycardia or fibrillation (VT/VF) or 3 or more appropriate discharges of an implantable cardioverter defibrillator (ICD) for VT/VF in a 24-hour period. We combined stellate ganglion blockade with epidural thoracic anesthesia to achieve rhythm control in a patient with a history of multiple episodes of VS that were not controlled with intravenous antiarrhythmic medication.

A patient in the early 40s was seen in the emergency department of our hospital with complaints of multiple discharges of his ICD. The patient was admitted to the cardiac intensive care unit and presented multiple episodes of VT. This led to the need for deep sedation with orotracheal intubation and mechanical ventilation. Intravenous lidocaine treatment was started but the patient had a recurrence of the episodes of VT. We decided to combine stellate ganglion block with epidural thoracic anesthesia. After the sympathetic block, there was no recurrence of the arrhythmic episodes. The patient was then transferred for ablation treatment.

We demonstrated the efficacy of both techniques in managing a patient with multiple episodes of ventricular storm. Sympathetic block and rhythm control were successfully achieved before transfer to another facility for definitive treatment.

While advances in regional anaesthesia have enhanced safety in anaesthetic procedures, systemic toxicity from local anesthetics (LAST) remains a significant risk. This risk is influenced by factors such as the method and location of anaesthetic application, and patient comorbidities. Lidocaine, in particular, is frequently implicated in these events.

We report the case of a 70-year-old female, 65kg, ASA-PS 4E, presenting with several comorbidities including frailty, hypertension, dyslipidemia, diabetes mellitus, heart failure, atrial fibrillation, and chronic pulmonary disease. The patient underwent urgent femoro-distal thromboembolectomy for acute lower limb ischaemia under monitored anesthesia care, with subcutaneous lidocaine administered by the surgeon.

The patient was administered 0.05mg of fentanyl and 0.625mg of droperidol intravenously, and 400mg of 2% lidocaine administered subcutaneously in fractioned doses in the femoral region. Approximately 2 minutes after lidocaine administration, the patient experienced a sudden altered state of consciousness, with disorientation and agitation, along with a rapid ventricular response in atrial fibrillation. Suspecting LAST, treatment with a 20% Intralipid® infusion was initiated, with a rapid restoration of her baseline mental and cardiac status. A subsequent CT scan confirmed the absence of acute cerebral events. After 24h in intensive care without further complications, the patient was discharged to the ward. The remaining postoperative course was unremarkable.

Prompt recognition and treatment of LAST are imperative, particularly in patients with significant comorbidities. This case highlights the need to consider the risk of systemic toxicity even with subcutaneous infiltration of local anesthetics, a procedure frequently performed with large volumes by non-anesthesiologists.

Myxomas represent the most prevalent primary cardiac neoplasms and are linked with a wide variety of symptoms which affect patients’ quality of life. We present a pioneering case employing erector spinae plane block (ESPB) for perioperative analgesia in a patient with a left atrial myxoma.

A 57-year-old white male presented in the emergency department with dyspnea on rest. His medical history included hyperlipidemia and bilateral carotid stenosis <40%. Preoperative assessments revealed a 3 x 4 cm myxoma of the left atrium, minor mitral and tricuspid regurgitation, with a good ejection fraction. The patient was led to surgery, for surgical excision of the myxoma. Anesthesia comprised of an ultrasound-guided, bilateral ESPB with ropivacaine 0.375%, 20 ml on each side and general anesthesia (induction with fentanyl, hypnomidate, propofol and rocuronium and maintenance with sevoflurane).

Hemodynamic stability was maintained throughout surgery without additional analgesia. Surgical duration was 100 minutes (extracorporeal circulation duration was 50 minutes), with a total anesthesia time of 135 minutes. After completion of surgery, the patient was extubated successfully and was transferred to the surgical ward, after staying at the post anesthesia care unit for 60 minutes. Postoperatively, the patient received intravenous paracetamol (1000 mg x 4), without the need of further analgesia and was discharged from the hospital after 3 days.

ESPB combined with general anesthesia provided effective perioperative analgesia for left atrial myxoma excision, facilitating hemodynamic stability and early postoperative mobilization and discharge. This case highlights the potential utility of ESPB in managing perioperative pain in cardiac surgery.

74-year-old woman with amyotrophic lateral sclerosis (ALS) with worsening symptoms over recent months, including relative immobility, slurring of speech, facial palsy, and mildly impaired swallowing/ dribbling presenting with an ankle fracture. AIMS : The primary objective was to prevent further neurological deterioration during the perioperative period while ensuring stability and pain management

Following evaluation, a decision was made to combine spinal anesthesia (SA) with popliteal sciatic and adductor canal blocks. High-risk consent was obtained from both the patient and family, outlining the relative risks of GA versus SA. 2.8ml of isobaric bupivacaine 0.5% without OPIOID was used for SA, while ultrasound-guided administration of 0.25% levobupivacaine (15ml each) was used for the nerve blocks. The patient was positioned on an Oxford pillow to mitigate reflux or aspiration, and no sedation was administered. The procedure proceeded without complications

Postoperatively, the patient was pain-free, awake, and comfortable. The nerve blocks facilitated a comfortable recovery without the need for strong opiates. Deep vein thrombosis prophylaxis commenced six hours post-surgery, and the patient managed well on oral analgesics. Vigorous chest physiotherapy, including incentive spirometry, ensured a complication-free recovery

ALS poses challenges in anesthesia management due to its progressive motor neuron degeneration. Debate persists regarding the choice of anesthesia, with spinal anesthesia potentially exacerbating neurological symptoms and GA carrying risks of respiratory depression and aspiration. Individualized decision-making is paramount. In this case, a low-dose opioid-free SA combined with peripheral nerve blocks yielded an uneventful recovery, highlighting the importance of tailored approaches in ALS patients

Femoral neuropathy is an uncommon complication associated with abdominal and pelvic surgical procedures, including cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Prolonged lithotomy positioning and compression by retractors are typical causes, with limited evidence regarding the role of intraoperative chemotherapy agents.

We report a case of a 57-year-old woman with adenocarcinoma of the cecum with peritoneal carcinomatosis. She underwent neoadjuvant chemotherapy prior to surgery with FOLFOXIRI, experiencing paresthesias in the extremities. Subsequently, she underwent cytoreductive surgery and HIPEC under general anesthesia combined with an epidural block, along with intra-abdominal instillation of mitomycin-C for 60 minutes. The surgery lasted 7 hours.

After surgery, the patient experienced decreased muscle strength in the right lower limb, inability to flex the thigh but maintaining dorsiflexion and plantar flexion, along with paresthesias in the anterior thigh and leg. The epidural catheter was removed, and she underwent lumbar and cranial computed tomography scans, which showed no significant alterations. Subsequently, electromyography revealed findings consistent with neurogenic compromise in the territory of the right femoral nerve. Due to persistent symptoms, she initiated physical therapy and was subsequently referred to a rehabilitation unit upon discharge.

Despite being documented in the literature, the etiology of perioperative femoral neuropraxia, remains uncertain. Risk factors include positioning, duration of surgery, prior chemotherapy, and pre-existing polyneuropathy, with the possibility of intra-abdominal chemotherapy contributing to neuropathic injury. Further research is warranted to elucidate the mechanisms underlying femoral neuropathy in this context, raising the possibility of a multifactorial etiology.

New neurological deficits after spinal surgery are rare but serious. A quick diagnosis and treatment are crucial to prevent permanent damage. We report a case of transient neurological deficit following endoscopic lumbar lateral recess decompression, likely caused by inadvertent ropivacaine diffusion into the epidural space.

A 58-year-old male, ASA-PS II, underwent endoscopic L5-S1 decompression for lumbar stenosis. He received general anesthesia and local anesthetic wound infiltration with 10 ml of 0.75% ropivacaine after surgery. Intraoperative period was uneventful. Upon emergence, the patient had no neurological deficits. Fifteen minutes later, he developed painless paraplegia and anesthesia below L3. MRI was unavailable, so a CT scan was performed.

The CT scan showed no abnormalities. Multidisciplinary team, consisting of orthopedic, neurology and anesthesiology consultants, agreed to prepare for an emergent decompressive laminectomy. However, on the way to the operating room, approximately 2h from new onset deficits, the patient's neurological symptoms started gradually improving. Surgery was halted, and the patient fully recovered within 3 hours. He was discharged home the next day fully recovered and with no further events.

This case suggests inadvertent ropivacaine spread to the epidural space as a possible cause of transient neurological deficits after lumbar spine surgery. Anesthesiologists should consider this in their differential diagnosis. Early CT scan can be helpful when MRI is unavailable.

Fat embolism (FE) syndrome is a rare but potentially fatal complication of long-bone fractures. Fat emboli can be scattered into the brain and cause serious damage that mimics traumatic axonal injury (TAI) on imaging. The diagnosis is clinical and challenging as signs and symptoms are highly variable, being the triad of hypoxemia, neurological impairment and petechial rash the most common.

A 17-year-old boy, victim of a bike crash without a helmet, was admitted to the hospital with a fracture of the right femur and tibia and traumatic brain injury (TBI) (without loss of consciousness nor acute injuries on neuroimaging). Both fractures were surgically stabilized under balanced general anesthesia immediately after, without complications. During his stay in the PACU, at 10h post-op, he developed progressive mental status deterioration with disorientation and drowsiness, associated with hypoxemia.

He was admitted to the ICU and 24h post-op, due to neurological status worsening, invasive mechanical ventilation was initiated as well as organ support treatment. A control TC-CE was performed and demonstrated findings compatible with TAI/FE confirmed on MRI posteriorly. Whilst in the ICU, axillary petechiae associated with increasing thrombocytopenia were detected. This case had a favorable evolution and he was re-intervened at D16 for tibial osteosynthesis without recurrence of those symptoms.

ES incidence after long bone fractures is about 0,9% to 11% and the average mortality rounds 10%. Due to its challenging diagnosis, classifications like the modified Gurd continue to be helpful as well as performing imaging exams, considering the MRI as the gold standard.

This audit was done at DHMC, Lahore to describe the labour epidural analgesia services. Labour epidural is the gold standard for pain relief in parturient. Date regarding epidural services and complication rate was very much scarce in Pakistan, when compared to developed countries. So, this audit will help us improving the practising standards at nation level.

This audit was done at DHMC, Lahore to describe the labour epidural analgesia services. Labour epidural is the gold standard for pain relief in parturient. Date regarding epidural services and complication rate was very much scarce in Pakistan, when compared to developed countries. So, this audit will help us improving the practising standards at nation level.

We will suggest to avoid lipid soluble drugs as possible and the use of dexmedetomidine instead for induction and maintenance of anaesthesia. And also to avoid inhalational anaesthetics, to avoid the risk of malignant hyperthermia. And to keep a maintain pressure gradient across LVOT, preload, after load and Blood pressure are to be maintained.

Pulmonary alveolar proteinosis(PAP) is a rare lung disease in which there is abnormal accumulation of lipoproteinaceous material in the alveoli, leading to alveolar obstruction and hence a spectrum of respiratory illness from mild to severe respiratory failure, that usually requires Whole-lung-lavage(WLL). We are presenting our case report of a patient with PAP who underwent WLL under general anaesthesia, and discuss the anaesthetic challenges and management strategies to maintain adequate lung isolation and oxygenation, use of recruitment manoeuvres for lavage lung and the role of multidisciplinary team workup.

A multidisciplinary team work with good communication, use of adequate backup plans, vigilant monitoring, meticulous lung separation with DLT, OLV with adequate PEEP, cautious use of positional manoeuvres and maintaining the vital parameters near or within normal range are indicators of good postoperative outcome in PAP patient.

Different scoring systems are used in predicting the health outcome and mortality rate of ICU patients. APACHE-II score has been found to have a discriminative value in predicting the mortality rate. There are some limitations to the use of this score such as the patients with multiple comorbid conditions and the physiological variables are all dynamic, that may alter the predicted mortality rate. This study is done in Surgical ICU (SICU) of DHMC, Lahore to see the diagnostic value of APACHE-II in predicting mortality rate and length of ICU stay.

Study Design: Prospective Cross-sectional Study Study Settings: Surgical ICU, Doctors Hospital and Medical Centre, Lahore, Pakistan Study Period: One year period from 1st December 2022 to 30th November 2023. Sampling Technique: Non-probability consecutive sampling All captured data were recorded and analysed in an Excel (Microsoft Corporation, USA) spreadsheet. Descriptive statistics were used. Continuous variable were compared using unpaired "t" test / Mann-Whitney test between groups and paired "t" test within groups at various follow-ups. Pearson Chi-square test, Fisher's exact test was used to find the association between the categorical variable. A p-value of less than 0.05 was considered statistically significant. The statistical analysis of data was done using the SPSS software for Windows, version 21.

Study on going. Will submit later when approved.

Hemophilia is associated with spontaneous bleeding in muscle tissues and joints. Repeated hemarthrosis results in progressive joint cartilage damage, leading to hemophilic arthropathy. Joint pain remains a problem for many patients, necessitating orthopedic interventions. Perioperative pain management is challenging: NSAIDs are unsuitable for their impact on platelet activity; opioids are often ineffective for movement-related pain and can lead to significant side effects. RA presents an option for effective pain management, but its safety remains unclear. We report the perioperative management of 4 hemophilic patients undergoing elective TKA, performing peripheral nerve block in a safe manner.

4 patients (age 41±12) underwent TKA; they all had severe hemophilia (3 type A, 1 type B). Tranexamic acid(1g) was administered via iv infusion 1 hour prior to surgery. FVIII/FVII was administered pre-induction and continued every 12h for 48h. After infusion, a single-shot US-guided femoral and sciatic nerve block was performed (levobupivacaine 0,375% 20ml + 20 ml respectively). General anesthesia was carried out; acetaminophen 1g, methadone 0,5 mg/kg and dexamethasone 4mg were administered. Postoperative opioid-sparing analgesia was successfully maintained with low-dose oral opioids(oxycodone/naloxone 5mg bid) for 48h, and acetaminophen.

No major hemorrhagic complications occurred. No muscle and soft tissue bleeding after RA were reported. Adequate pain management enabled early physical rehabilitation.

The perioperative use of regional nerve blocks proved to be safe and effective for opioid-sparing analgesia in hemophilia patients undergoing TKA, enabling early physical rehabilitation. Our findings suggest that with appropriate clotting factor replacement, RA can be a viable option in this patient population.

The aim of this case is to prevent the accidents that happen in the operating room with the drugs used in anesthesia.Mistakes happened sometimes specially when there is a resemblance between the vials or the ampoules of two or several drugs and because the anesthesiologist do not check(why?- due to his respect and confident to the nurse-anesthetist)the name of the drugs marked on the ampoule opened and handled by the nurse-anesthetist

It is a case of two patients with hip fracture scheduled to be operated for total hip replacement.The patients were females 65 and 72 years old with coronary heart disease hypertension and diabetics 2 type and dyslipidemia.They were well controlled by their medicament The anesthesia consisted of spinal anesthesia with femoral block for post-operative pain management.The first female(65y) received a spinal anesthesia with bupivacaine 0.5% -2 ml hyperbaric with 0.5 ml of morphine sulphate(the vial given accidentally instead of sufentanil ampoule).A femoral block with bupivacaine 0.5%-7ml isobaric was done under ultrasound.The second patient (72y) received the same protocol of anesthesia but with 1 ml of morphine sulfate.

The first patient operation went smoothly without hemodynamic complications only a pruritus at the end was settled and took 2 days to resolve.It was treated by dexamethasone 8 mg iv /8h.Naloxone was given at the end of the operation the patient was pain free for 3 days.The second patient collapsed during the operation she was maintained by phenylephrine and sent to the icu then intubated for one day

Double checking prevent accident