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Introduction Ultrasound-guided fascial plane blocks are nowadays the gold standard technique for regional anesthesia and postoperative analgesia. Despite their high success rate, cases of partial or total failure of this method have been reported. This experimental study aims to address the corresponding ultrasound signs and their association with fascial plane block efficacy. Methods After capturing the appropriate sonographic image that included muscle layers and their fasciae, an 18-gauge epidural needle penetrated the cadaveric porcine tissue and was forwarded until the tip of the needle reached the target fascial plane. The infusion of methylthioninium chloride or methylene blue dye was performed, causing tissue hydro dissection. The documentation of the generated ultrasound images was followed by surgical exposure of the tip of the needle. Results The distribution of the dye into the plane of interest (double-edge sign) was equivalent to block success, whereas the single-edge sign (accumulation of the dye between fascia and epimysium) indicated total block failure. The intermediate-edge sign, a combination of the previous ultrasound signs, is related to partial failure of block performance. Conclusion The identification of the three novel sonographic signs is an accurate predictive factor of peripheral nerve block efficacy. The respective data are expected to aid the rapid improvement of interfascial plane block accuracy and techniques, leading to their more effective execution and simultaneously eliminating the failure rates. Thereby, the amelioration of intra and postoperative analgesia will be accomplished, expediting the patient's hospital discharge and reducing or even avoiding opioid consumption.

Lung ultrasound contributes to the diagnosis of perioperative pulmonary edema due to fluid overload and impairment of renal function. Laparoscopic surgery and the patient's intraoperative position can facilitate the emergence of these disturbances as well. A 34-year-old female patient underwent laparoscopic salpingectomy and ovarian resection in the Trendelenburg position because of an unruptured ectopic pregnancy. The large fluid volume administration pre- and intraoperatively and the intraoperative low urine output led to the development of interstitial pulmonary edema before extubation. The formation of comet-tail lines at the lung ultrasound indicated the administration of diuretic therapy, followed by the improvement of the patient's cardiopulmonary status, urine excretion, and extubation. A subsequent chest X-ray verified the foregoing findings. Lung ultrasound enables the quick and accurate diagnosis of interstitial edema. The early administration of diuretic therapy eliminates the potential of the patient's prolonged postoperative hospitalization, even in the intensive care unit.

The technique of visualizing the vocal cords during direct laryngoscopy has made the Macintosh laryngoscope (HEINE Optotechnik GmbH & Co. KG, Gilching, Germany) the optimal choice for endotracheal intubation since the middle of the 20th century. On the other hand, the use of full personal protective equipment during the SARS-CoV-2 pandemic impeded the successful completion of medical procedures, such as endotracheal intubation during cardiopulmonary resuscitation in patients infected with COVID-19. These circumstances necessitated the development of a new type of laryngoscope, the Vie Scope (Adroit Surgical LLC, Oklahoma City, OK, USA). A single-blind, randomized, prospective, superiority clinical trial was conducted. Patients with an expected easy airway were enrolled and allocated in a 1:1 ratio to either the Vie Scope or Macintosh. The first-attempt intubation success rate and the required intubation time were defined as primary outcome measures, while the overall intubation success rate and glottis visualization, as classified by the Cormack-Lehane scale, were considered secondary outcomes. This study included 264 patients. The required intubation time was shorter with the Macintosh than with the Vie Scope (median (interquartile range (IQR)): 7.80 (1.50) and mean (standard deviation (SD)): 8.08 (5.34) seconds vs. median (IQR): 15.65 (3.90) and mean (SD): 16.65 (5.02) seconds, difference in means: 8.60 seconds, 95% CI: -∞ to 7.9, p<0.0001). The first-attempt intubation success rate was estimated at 100% (132/132) and 90.15% (119/132) using the Macintosh and Vie Scope, respectively (relative risk: 0.90 (=1/1.1, 95% CI: 0.85-0.95), p=0.0002). Furthermore, a higher overall intubation success rate was noted with the Macintosh (132/132, 100%) than with the Vie Scope (124/132, 93.94%), p=0.0041. No statistically significant difference was detected between the laryngoscopes regarding the degree of the glottis visualization (p=0.7895). The first-attempt and overall intubation success rates, as well as the required intubation time with the Macintosh, were superior to those with the Vie Scope when used for the establishment of anticipated easy airways, without a statistically significant difference in glottis visualization grade.

Background and AimsA 75-year-old female patient with a history of arterial hypertension, managed with ACE inhibitors, underwent posterior thoracic and lumbar spinal fusion (T11-L5) for lumbar spinal stenosis (L1-L4). General anesthesia was induced with propofol 1%, rocuronium, and fentanyl, while maintenance was achieved with sevoflurane and remifentanil, guided by bispectral index monitoring to maintain an appropriate anesthetic depth. The patient remained hemodynamically stable throughout the 3-hour operation.MethodsBefore emergence from general anesthesia and extubation, a bilateral ultrasound-guided Erector Spinae Plane (ESP) Block was performed at T8 level with the patient in prone position. A single shot of 20 ml ropivacaine 0.375% and 50 mcg clonidine was implemented on each side. Afterwards, the patient was transferred to the postanesthetic care unit and was discharged 60 minutes later, as her cardiopulmonary status was stable, accompanied by a low pain score (VAS=2/10) postoperatively.ResultsAround 80 minutes after the patient‘s admission to the Orthopedic Department, significant hypotension was observed, with a systolic blood pressure of 68 mmHg. Physical examination revealed no sensory, motor, or reflex abnormalities in the lower extremities, nor any other signs of local anesthetic toxicity. Laboratory tests and imaging studies were also within normal range. Suspecting ESP block-induced hypotension, continuous hemodynamic monitoring was initiated, along with the administration of 1000 ml Ringer’s lactate solution containing 12 mg of noradrenaline, in order to maintain systolic blood pressure above 110 mmHg. Subsequently, the infusion rate was gradually reduced, and after 48 hours the patient was stabilized hemodynamically, requiring no analgesic regimen.ConclusionsESP block-induced hypotension was attributed to the spread of local anesthetic into the paravertebral and epidural space, along with the administration of clonidine and high dose of local anesthetic. Hence, we advocate the infusion of dilute local anesthetic solutions and advise against the use of clonidine in elderly patients receiving antihypertensive therapy.

Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less)Background and AimsA 25-year-old male presented following a motor vehicle accident with multiple right-sided rib fractures, pulmonary contusion, a small pneumothorax, and thoracolumbar spine fractures (figures 1, 2). Due to the extent of his injuries, emergency spinal fusion was indicated. On admission, he was hemodynamically stable but had hypoxemia (SpO2 95% on 50% Venturi mask, 91% on room air), tachypnea, dyspnea, and severe inspiratory pain.MethodsTo optimize analgesia and limit respiratory depression, an ultrasound-guided erector spinae plane (ESP) block was performed at the T8 level. General anesthesia included sevoflurane (1–1.2%) and fentanyl (250 µg). Surgery lasted two hours. Postoperatively, pain relief and oxygenation improved significantly (figure 3).ResultsMild pain (VAS 2/10) recurred after 20 hours, and a continuous ESP block was initiated using ropivacaine 2% (6 ml/h), maintained for 60 hours. Upon completion, oxygen saturation on room air was 96%. The patient was discharged on postoperative day 5.Abstract P220 Figure 1Vertebrae fracture[Image Omitted. See PDF.]Abstract P220 Figure 2Rib fractures[Image Omitted. See PDF.]Abstract P220 Figure 3Spine fusion, small right pneumothorax, ESP catheter[Image Omitted. See PDF.]ConclusionsTo our knowledge, this is the first case describing the use of an ESP block for thoracolumbar spinal fusion in a patient with rib fractures and hypoxemia. In such scenarios, the ESP block offers not only effective analgesia but also prevention of respiratory complications such as atelectasis, pneumonia, and worsening hypoxemia. It facilitates timely surgical intervention, reduces morbidity, and shortens hospitalization.