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Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page) Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less)Background and AimsThis case report highlights the successful treatment of excessive sweating related to Intrathecal (IT) morphine with atropine.MethodsA 23-year-old male patient, weighing 70 kg and measuring 172 cm, referral to our clinic for segmentectomy. Preoperative vital signs were normal. After obtaining consent from the patient, spinal analgesia was performed 350 mcg of IT morphine. Anesthesia induction was achieved with propofol, rocuronium bromide, and remifentanil. A double-lumen endotracheal tube was placed in the left main bronchus. Forced-air warming was used to prevent hypothermia. Video-assisted thoracoscopic surgery was performed on the left hemithorax, and the mass was excised. Sweating was observed on the patient‘s head and upper body starting from the second hour of the operation. No other intraoperative complications occurred. Three hours later, extubation was performed with suggamadex. Upon arrival in the recovery room, the body temperature was 33.2°C. The patient continued to experience excessive sweating. 0.5 mg of atropine was administered and miraculously, the sweating stopped within 1-2 minutes. With the normalization of vital signs and body temperature, the patient was transferred to the ward. As the patient remained asymptomatic during follow-ups, he was discharged on the second postoperative day.ConclusionsRarely, excessive sweating accompanied by hypothermia can be observed after IT opioid injection. Among the active treatment options, naloxone and lorazepam are included. Atropine is suggested as an option. Acetylcholine is the main pre- and postganglionic neurotransmitter of the sympathetic nervous system that innervates sweat glands, thus the use of anticholinergic medication like atropine significantly reduces or eliminates sweating.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page) Application for ESRA Abstract Prizes: I don’t wish to apply for the ESRA PrizesBackground and AimsSingle-shot neuraxial techniques are not useful for most labor analgesia. Intravenous patient-controlled analgesia (iv-PCA) is indicated for parturients who cannot receive neuraxial analgesia. We present two cases managed with a combined single-shot technique and iv-PCA.MethodsCase 1: A 37-year-old, G1P0 woman presented at 19 weeks gestation for abortion indicated with fetal abnormalities. She had a medical history of thoracic to lumber spine surgery for scoliosis. We determined continuous epidural analgesia was not possible and choose a combination of single- shot spinal anesthesia combined with iv-PCA. Before cervical dilatation procedures, 200 mcg of morphine with 7.5mg of bupivacaine was administered intrathecally using a 25-gauge needle. Following induction with prostaglandin E2, iv-PCA with fentanyl (10 mcg/h, 25 mcg/bolus, lockout time 10 min) was initiated. Standard monitors were placed, and the respiratory monitored with ETCO2 continuously until 24 hours after administration. The low dose of naloxone was administered to manage opioid side effects such as pruritus or nausea. Pain control during labor was adequate and the parturient was delivered without serious complications. Case 2: A 27-year-old, G5P0 presented at 21 weeks gestation for abortion indicated with a fetal abnormality. She was not eligible for epidural analgesia due to anticoagulant therapy. 200 mcg of morphine with 10mg of bupivacaine was administered and then the same protocols were used in this parturients. Pain control during labor was good and opioid side effects were well controlled with naloxone.ConclusionsA single-dose technique combined with iv-PCA provided adequate labor analgesia in mid-term delivery without serious complications.

Please confirm that an ethics committee approval has been applied for or granted: Yes: I’m uploading the Ethics Committee Approval as a PDF file with this abstract submission Application for ESRA Abstract Prizes: I don’t wish to apply for the ESRA PrizesBackground and AimsGynecological oncology surgery is associated with large abdominal incisions, extensive dissection, and a more pronounced inflammatory response with a more challenging pain profile. The current study hypothesized that the analgesic efficacy of combined quadratus lumborum block (QLB) and sacral erector spinae block (ESB) is non-inferior to intrathecal morphine(ITM) in patients undergoing open gynecological oncological surgery with midline incision.MethodsAfter getting IEC approval 84 ASA 1&2 patients aged 18-65 years scheduled for open gynecological surgery were randomized to receive ITM 200mcg (Group A) or bilateral QLB (20 ml 0f 0.25% ropivacaine with adrenaline 1: 2,00,000 on each side) and 10 ml on each side for sacral ESB (Group B). The primary objective was to compare the 24-hour morphine consumption. Sensory assessment, time to first rescue, VAS score at different time intervals, quality of recovery score, and 48-hour analgesics consumption were secondary objectives.ResultsMedian 24-hour morphine consumption was comparable with 18 mg (IQR 3.5- 26) in group A and 11 mg (IQR 5 – 24) in group B. The difference between the mean was 4.54 with 95% CI (-1.16 to 10.24). The non-inferiority margin was 5 and the 95% confidence interval is crossing 0 proving the non-inferiority. The VAS score at rest and movement was comparable between the two groups, however at 48 hrs (movement) group B showed a statistically significant reduction.Abstract OP054 Figure 1CONSORT diagramAbstract OP054 Table 1Perioperative analgesic consumptionAbstract OP054 Figure 2Non-inferiority marginConclusionsCombined QLB with sacral ESB is non-inferior to ITM in terms of perioperative analgesia and quality of recovery in patients undergoing gynecological oncology surgery

Scoliosis Is an abnormal lateral curvature of the spinal column. Cobb angle of 10 degrees regarded as a minimum angulation to define it. The most common form of scoliosis is idiopathic.Preoperative evaluation include assessment for the presence and severity of pulmonary dysfunction from restrictive lung disease. It`s unlikely will improve during scoliosis surgery and may make intraoperative and postoperative ventilation challenging. Significant postoperative atelectasis should be anticipated, and in severe cases of scoliosis, prolong postoperative ventilation may be required. Cardiac function is one more important side that we have to consider. Regional hypoventilation caused by abnormal diaphragm movement and chronic hypercarbia and hypoxemia from advanced pulmonary disease can lead to pulmonary hypertension and of the right ventricle failure.A large incision may lead to loss of up to one half of a patient’s blood volume. To prevent haemorrhage complication next steps are require: preoperative iron supplementation or erythropoietin, Cell Saver mashing, Deliberate hypotension, arterial access for PPV, SVV and CO, goal directed fluid therapy, Thromboelastography, proper prone positioning, neuromonitoring.Due to the large wound area and traumatic spinal correction, patients suffer from severe pain immediately after scoliosis surgery. The treatment of this postoperative pain remains one of the major challenges in scoliosis surgery, and insufficient treatment can increase postoperative morbidity, complication rates, and length of hospitalization.We have following options – epidural anaesthesia, intrathecal morphine, Lidocaine iv and ketamine, ESP block.Epidural founds its place in pain management after spinal surgery. Epidural catheter can be used as an effective means of postoperative pain management for children with scoliosis, it is more effective than intravenous patient-controlled analgesia in postoperative pain management after posterior spinal fusion. It accelerates postoperative mobilization, independent ambulation, and decries duration of hospital stay. Epidural anaesthesia without opioids is a safe and sufficient method to regulate postoperative pain in patients even with neuromuscular scoliosis and respiratory impairment. There are some limitations that we should consider. Catheters might be an additional source of infection by channelling the way for bacteria during their application. It may get stuck in surrounding tissues or even rupture. Catheter is installed after the surgery, and it does not reduce pain intraoperatively, therefore, amount of opioids during surgery remains to be substantial.Intrathecal morphine injectionA lot of studies carry out conclusion that intrathecal morphine reduces postoperative pain and opioid consumption in the 24 hours following spine surgery. There are some evidences that intrathecal opioids may decrease intraoperative blood loss, though the mechanism of the blood-sparing effect remains unclear. Some hypothesize that the diminished blood loss may be due to lower mean arterial pressures. Nevertheless, other studies have demonstrated no difference in blood pressures. In spite of all benefits, we should keep in mind several possible complications associated with intrathecal morphine.Respiratory depression and sedationIt can be sufficiently severe and require escalation of care and readmission to ICU.Other complications – post dural puncture headache, cerebrospinal fluid leaks and surgical site infections. Morphine has the side effect – nausea, vomitingWe should be aware of the risk-to-benefit ratio when deciding whether to administer ITM for postoperative pain management.Lidocaine and ketamine have no relation to regional methods of anaesthesia, nevertheless booth this method achieves the same goals – they reduce postoperative pain and opioid consumption.Lidocaine iv improved pain scores and reduced 48-h opioid requirements in patients undergoing spine surgery. Patients given lidocaine had slightly fewer 30-day complications than patients given placebo. IV lidocaine improved the postoperative gastrointestinal function. Lidocaine reduces postoperative nausea, vomiting and the supply of antiemetics. Functional walking capacity distance increased significantly in lidocaine-treated children.The analgesic effect of lidocaine is diversified. This drug has peripheral and central actions, which reduces neural responses to pain. Lidocaine suppresses spontaneous impulses generated from injured nerve fibres and the proximal dorsal root ganglion.Lidocaine does not adversely affect the monitoring of motor evoke and somatosensory-evoked potentials in individual patients during surgery and can be used as an adjunctive medication with TIVA regimens to reduce the required dose of other MEP suppressing medications.Ketamine at sub-anaesthetic doses, has been shown to modulate nociceptive hypersensitization through its antagonist effects on NMDA receptors by blocking pain signalling input Several studies have demonstrated that the addition of intraoperative and postoperative intravenous ketamine infusion can reduce the amount of morphine equivalents consumed in the 48-h postoperative time period, founding the effects of ketamine on the pain control regimen. Additionally, significant reduction in the incidence of nausea and vomiting provides an additional benefit of ketamine. Yet, other studies conclude that ketamine reduces the amplitude and increases the latency of transcranial electrical MEP.ESP block, due to the peculiarity of the innervation of the spinal column, shows the best results in reduction of pain after spine surgery. Resent MRI studies on cadavers and healthy volunteers confirm the spread of anaesthetic to the dorsal ramus of the spinal nerve, which innervates the muscles, soft tissues around spine column, and transverse processes of the spine.Further studies demonstrate a significant reduction in the opiate use with lower rates of pain intensity after lumbar spine surgeries. Moreover, we have first clinical cases that describes successful performing ESP block in scoliosis surgery.ESP is volume dependent block. To reach paravertebral and epidural spaces and effect ventral ramus of the spinal nerve at several levels high volume of anaesthetic is required. But, for spine surgery we need to effect only dorsal ramus, so we can reduce the volume of anaesthetic, and inject it bilaterally on two levels in order to block more spine levels as much as possible to place of screws implementation.Apparently, we will not affect motor evoked potentials, considering that we block only the dorsal branch of the spinal nerve, but further researches are required.Spine surgeries belongs to the most traumatic intervention and may conduct pronounce postoperative pain. If it treated not appropriately, it can lead to hyperalgesia and chronic pain. The incidence of moderate to severe chronic postsurgical pain at 12 months after spine surgeries can reach up to 39.1%All methods of anaesthesia discussed today has impact on pain perceiving from various sides. Some of them, affects transduction, transmission, and modulation by interrupting the conduction of the pain impulse, another affects perception by reducing sensitization and tolerance to pain by reducing the quantity of narcotic analgesics. Due to this mechanism, the essential balance between nociception and antinociception is sustained.

Purpose The objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use. Methods This was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24–48 h and 48–72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series. Results There were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] ( p  < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort ( p  = 0.005). Conclusions The implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy.

Aberrant mechanosensation has an important role in different pain states. Here we show that Epac1 (cyclic AMP sensor) potentiation of Piezo2-mediated mechanotransduction contributes to mechanical allodynia. Dorsal root ganglia Epac1 mRNA levels increase during neuropathic pain, and nerve damage-induced allodynia is reduced in Epac1−/− mice. The Epac-selective cAMP analogue 8-pCPT sensitizes mechanically evoked currents in sensory neurons. Human Piezo2 produces large mechanically gated currents that are enhanced by the activation of the cAMP-sensor Epac1 or cytosolic calcium but are unaffected by protein kinase C or protein kinase A and depend on the integrity of the cytoskeleton. In vivo , 8-pCPT induces long-lasting allodynia that is prevented by the knockdown of Epac1 and attenuated by mouse Piezo2 knockdown. Piezo2 knockdown also enhanced thresholds for light touch. Finally, 8-pCPT sensitizes responses to innocuous mechanical stimuli without changing the electrical excitability of sensory fibres. These data indicate that the Epac1–Piezo2 axis has a role in the development of mechanical allodynia during neuropathic pain. Mechanical allodynia describes the process whereby innocuous stimuli is perceived as being noxious and is a common symptom of neuropathic pain. Using mice deficient in the cAMP sensor Epac1, the authors in this study find that Epac1 regulates mechanical allodynia by sensitizing the mechanotransducer Piezo2.

Objectives: Intrathecal morphine (ITM) is an efficacious method of providing postoperative analgesia and reducing pain associated complications. Despite adoption in many surgical fields, ITM has yet to become a standard of care in lumbar spine surgery. Spine surgeons’ reticence to make use of the technique may in part be attributed to concerns of precipitating a cerebrospinal fluid (CSF) leak. Methods: Herein we describe a method for oblique intrathecal injection during lumbar spine surgery to minimize risk of CSF leak. The dural sac is penetrated obliquely at a 30° angle to offset dural and arachnoid puncture sites. Oblique injection in instances of limited dural exposure is made possible by introducing a 60° bend to a standard 30-gauge needle. Results: The technique was applied for injection of ITM or placebo in 104 cases of lumbar surgery in the setting of a randomized controlled trial. Injection was not performed in two cases (2/104, 1.9%) following preinjection dural tear. In the remaining 102 cases no instances of postoperative CSF leakage attributable to oblique intrathecal injection occurred. Three cases (3/102, 2.9%) of transient CSF leakage were observed immediately following intrathecal injection with no associated sequelae or requirement for postsurgical intervention. In two cases, the observed leak was repaired by sealing with fibrin glue, whereas in a single case the leak was self-limited requiring no intervention. Conclusions: Oblique dural puncture was not associated with increased incidence of postoperative CSF leakage. This safe and reliable method of delivery of ITM should therefore be routinely considered in lumbar spine surgery. Note technique à propos de l’injection intrathécale oblique lors d’une chirurgie à la colonne lombaire. Objectifs : L’injection intrathécale de morphine (ITM) est un moyen efficace d’analgésie postopératoire et aide à diminuer la douleur associée aux complications. Malgré son adoption dans plusieurs domaines chirurgicaux, l’ITM n’est pas encore devenue la norme en chirurgie de la colonne lombaire. La réticence des chirurgiens qui pratiquent ce type de chirurgie à utiliser cette technique pourrait être due en partie à la crainte de provoquer une fuite de liquide céphalorachidien (LCR). Méthodologie : Nous décrions une méthode d’injection intrathécale oblique pendant la chirurgie de la colonne lombaire pour minimiser le risque de fuite du LCR. Le sac dural est pénétré obliquement à un angle de 30° afin de décaler les sites de ponction au niveau dural et arachnoïdien. Une injection oblique dans le cas d’un accès dural limité est rendue possible en courbant une aiguille de calibre 30 à 60°. Résultats : La technique a été utilisée pour ITM ou injection de placebo chez 104 patients lors d’une chirurgie à la colonne lombaire dans le contexte d’une étude randomisée contrôlée. L’injection n’a pas été effectuée chez 2 sujets (2/104, 1,9%) à cause d’une déchirure durale survenue préalablement. Chez les 102 autres sujets, aucune fuite de LCR attribuable à l’injection intrathécale oblique n’est survenue. Une fuite transitoire de LCR a été observée immédiatement après l’injection intrathécale chez 3 sujets (3/102, 2,9%), sans séquelle associée ou nécessité de réintervention après la chirurgie. Chez 2 sujets, la fuite observée a été réparée en la scellant avec de la colle de fibrine alors que chez l’autre sujet aucune intervention n’a été nécessaire. Conclusions : Une ponction durale oblique n’a pas été associée à une incidence accrue de fuite du LCR en période postopératoire. Cette méthode sûre et fiable d’ITM devrait donc être envisagée de routine dans la chirurgie de la colonne lombaire.

Despite the potential for faster postoperative recovery and the ease of direct intraoperative injection, intrathecal morphine is rarely provided in lumbar spine surgery. To evaluate the safety and efficacy of intrathecal morphine following lumbar fusion. We randomly assigned 150 patients undergoing elective instrumented lumbar fusion to receive a single intrathecal injection of morphine (0.2 mg) or placebo (normal saline) immediately prior to wound closure. The primary outcome was pain on the visual-analogue scale during the first 24 h after surgery. Secondary outcomes included respiratory depression, treatment-related side effects, postoperative opioid requirements, and length of hospital stay. An intention-to-treat, repeated-measures analysis was used to estimate outcomes according to treatment in the primary analysis. The baseline characteristics of the 2 groups were similar. Intrathecal morphine reduced pain both at rest (32% area under the curves [AUCs] difference, P < .01) and with movement (22% AUCs difference, P < .02) during the initial 24 h after surgery. The risk of respiratory depression was not increased by intrathecal morphine (hazard ratio, 0.86; 95% confidence interval, 0.44 to 1.68; P = .66). Although postoperative opioid requirements were reduced with intrathecal morphine (P < .03), lengths of hospital stay were similar (P = .32). Other than a trend towards increased intermittent catheterization among patients assigned to intrathecal morphine (P = .09), treatment-related side effects did not significantly differ. The early benefits of intrathecal morphine on postoperative pain were no longer apparent after 48 h. A single intrathecal injection of 0.2 mg of morphine safely reduces postoperative pain following lumbar fusion.

We hypothesized that pericapsular nerve group (PENG) block was non-inferior to intrathecal (IT) morphine regarding analgesia after total hip arthroplasty (THA) with no untoward effects on the motor function. In a double-blind placebo-controlled non-inferiority trial, patients undergoing unilateral THA under spinal anesthesia were randomized to receive a PENG block (20 mL 0.5 % levobupivacaine +2 mg dexamethasone) or IT morphine (100 μg). They received multimodal oral postoperative analgesia with rescue intravenous morphine for breakthrough pain, and were repeatedly evaluated for pain over the first 48 postoperative hours using a 0–10 numerical rating scale (NRS), and for the straight leg raise test at 4, 6 and 12 h. Co-primary outcomes were (i) maximum pain at rest and (ii) at active hip flexion – estimated for the overall period based on three consecutive scores – and (iii) milligram morphine equivalents (MME) delivered over 48 h. Non-inferiority margins for the PENG block – IT morphine differences were 0.75 NRS points for the pain scores, and 10 for the cumulative MME (corresponds to one 4 mg intravenous morphine rescue dose). All randomized patients (N = 60, 1:1 ratio) completed all trial procedures. PENG block – IT morphine differences in the maximum pain at rest (difference = 0.182, 95 %CI -0.218 to 0.582) and at hip flexion (difference = −0.270, 95 %CI -0.990 to 0.453) were well below 0.75 NRS points, and the difference in MME (difference = −2.1, 95 %CI -6.5 to 1.9) was well below 10 MME. Age-adjusted straight leg raise test failure rates were similar in the two groups (11.7 % vs. 12.8 %, difference = −1.1, 95 %CI -9.7 to 7.5). Compared to IT morphine, PENG block provides non-inferior analgesia after THA under spinal anesthesia without additional compromise of the motor function. Trial registration number: NCT05308420 [Display omitted] •PENG block and IT morphine are both used for postoperative analgesia in hip surgery.•We compared efficacy and safety of PENG block and IT morphine in THA.•Regarding analgesia, PENG block appeared non-inferior to IT morphine.•PENG block showed no propensity towards higher muscle function impairment.

Background Nalbuphine, a synthetic k -agonist and µ -antagonist, provides efficient pain relief while reducing opioid-related adverse effects. This study aims to compare the efficacy of intrathecal nalbuphine (ITN) with intrathecal morphine (ITM) for post-TKA pain. Methods A retrospective cohort analysis of 131 patients who underwent TKA with spinal anesthesia (SA), a single shot of adductor canal block, and periarticular injections was conducted. The patients were divided into 2 groups, Group N received 0.8 mg nalbuphine, and Group M received 0.2 mg morphine as an adjuvant to SA. Propensity-score matching was employed to compare the visual analog scales (VAS) of postoperative pain intensity, cumulative morphine use (CMU), maximum knee flexion angle, straight leg raise (SLR) ability, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (LHS). Results The mean VAS of group M were significantly lower than group N at 6, 12, 18, and 24 h ( P  < 0.01). Group M had lower CMU than group N at 24 h ( P  < 0.01) and 48 h ( P  < 0.01), while there was no significant difference between groups in terms of knee flexion angle and SLR at any time point. Additionally, 29.3 and 57.9% of patients in group N and M experienced PONV, respectively ( p  = 0.04), and group N had significantly shorter LHS compared to group M ( P  < 0.001). Conclusion Although, intrathecal morphine (ITM) still provides better pain control particularly in the first 24 h, patients who received intrathecal nalbuphine (ITN) had significantly fewer incidence of PONV, and shorter LHS.