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BackgroundWe compared the spread of an injectate into the thoracic sympathetic chain resulting from a single-injection intertransverse process (ITP) block with that of a single-injection PV block at the T2 level.MethodsSixteen soft-embalmed cadavers were used. The right hemithorax was randomly allocated to receive either an ultrasound-guided single-injection ITP block or ultrasound-guided single-injection PV block at the T2 vertebral level, with the opposite block administered to the other side. Approximately 10 mL of latex dye solution was injected into each hemithorax using a random allocation technique. The presence of dye at the nerve root in the sympathetic chain and intercostal nerves at the injection and additional levels was examined by dissection.ResultsThe injectate spread into the T2 sympathetic ganglion on both ITP (11/16, 68.8%) and PV (16/16, 100%) blocks. The ITP block demonstrated greater uniformity of dye staining in both the dorsal rami and dorsal root ganglion, which contrasts with the less consistent staining outcomes of the PV block in these regions.ConclusionsAt the T2 level, we observed a lower efficacy of the ITP block for analgesic coverage of the sympathetic nerve. This suggested a potential preference by clinicians for the application of the T2 PV block over the ITP block, specifically for the management of sympathetically maintained pain in the upper extremities. In addition, our findings may hint at the potential advantages of the ITP block in specific clinical contexts where targeted nerve involvement, such as the medial branch block or dorsal root ganglion block, is sought.

Postoperative visceral pain remains a major challenge following laparoscopic hysterectomy. While stellate ganglion block (SGB) is increasingly utilized for acute and chronic pain management, limited evidence exists regarding its efficacy in modulating visceral pain after gynecologic laparoscopy. This study aimed to evaluate whether ultrasound-guided SGB could reduce early postoperative visceral pain intensity and opioid consumption. In this prospective, randomized controlled trial, 90 patients undergoing laparoscopic hysterectomy were allocated (1:1:1) to receive ultrasound-guided SGB combined with transversus abdominis plane block (TAPB) (SGB group), TAPB alone (TAP group), or no nerve block (control group). The primary outcome was visceral pain intensity, assessed using visual analog scale (VAS) scores at rest and during movement at 1, 3, 6, 24, and 48 hours postoperatively. Secondary outcomes included rescue analgesia requirements and complications. The linear mixed-effects model revealed that the SGB group exhibited a significantly greater reduction in visceral pain intensity at rest and during movement at 1, 3, and 6 hours compared to the TAP and control groups (P < 0.05). Notably, the percentage of patients requiring rescue analgesia was significantly lower in the SGB group compared to the TAP and control groups (14.3% vs. 32.1% and 48.1%, respectively, P < 0.05). No statistically significant differences in incisional pain were detected among the three groups at any time point (P > 0.05). Ultrasound-guided SGB effectively alleviates early postoperative visceral pain and reduces opioid demand, supporting its role as a valuable addition to multimodal analgesia protocols in laparoscopic hysterectomy.

Background Celiac plexus block has been commonly utilized for the treatment of chronic pancreatitis-associated abdominal pain. Prospective studies suggest efficacy in 30 to 50% of patients, although no randomized sham-controlled trials have been performed. The objective of this study is to assess the effect of endoscopic ultrasound (EUS)-guided celiac plexus block on abdominal pain in patients with documented chronic pancreatitis. Methods This is a two-arm randomized sham-controlled trial with blinded evaluators. The study will be conducted at multiple academic sites in the United States who are members of the United States Pancreatic Disease Study Group (USPG). Patients referred for EUS to exclude chronic pancreatitis as a cause of abdominal pain as well as those with established painful chronic pancreatitis undergoing EUS for another indication will be eligible. At the time of EUS with confirmation of chronic pancreatitis by standard EUS diagnostic criteria, patients will be randomized to either celiac plexus block or sham whereby an anesthetic and steroid combination will be injected into the celiac plexus or saline will be injected into the gastric lumen with the same type of needle as used for celiac plexus block, respectively. The main outcome measure will be a 50% reduction in abdominal pain using the Brief Pain Inventory Short Form (BPI-SF) at 1 month post-intervention. A number of secondary outcomes will be measured including visual analog scale (VAS), Comprehensive Pain Assessment Tool Short Form (COMPAT-SF) pain scores, and quality of life using a pancreas-specific validated measure (PANQOLI). Discussion In this study, the effect of celiac plexus block on abdominal pain in patients with chronic pancreatitis will be compared to a sham intervention. This randomized trial will offer a definitive assessment of the role of celiac plexus block for the treatment of abdominal pain in this setting. Trial registration {2} ClinicalTrials.gov NCT 06178315. Registered on December 21, 2023

Background Effective management of both incisional and visceral postoperative pain during open abdominal surgery is crucial for patient recovery. This study evaluated the effect of celiac plexus block on postoperative pain and recovery. Methods This single-center, patient-assessor-blinded, blank-controlled randomized clinical trial was conducted from March 9, 2022, to November 12, 2023. A total of 78 patients scheduled for open Whipple surgery were randomized. The intervention involved either receiving a celiac plexus block (Group NB) with 20 ml of 0.5% ropivacaine during surgery or not receiving the block (Group GC). Both groups received traditional postoperative analgesia. The primary outcome was opioid consumption within 72 h post-surgery. Secondary outcomes included the frequency of analgesic pump presses, pain scores, hemodynamic parameters before and after nerve block as well as postoperatively, levels of postoperative inflammatory markers, time to first flatus, length of postoperative hospital stay, and perioperative complications. Results Among the 78 patients enrolled, 37 were randomized to receive intraoperative celiac plexus block and 41 were not. In total, 12 patients (8 in group GC and 4 in group NB) were excluded because of protocol deviations, and 66 patients (33 in each group) were included in the per-protocol analysis. Group NB demonstrated significantly lower total opioid consumption within the first 72 h post-surgery than group GC (mean (SD), 66 (18.8) mg vs. 88.9 (21.2) mg, respectively; P  < 0.01). Pain scores assessed using the Visual Analog Scale were consistently lower in group NB at all postoperative time points (all P  < 0.05). The first press of the patient-controlled analgesia (PCA) pump occurred significantly later, and the daily frequency of PCA pump presses was lower in group NB. The time to first flatus and length of postoperative stay were shorter in group NB but not statistically significant. Only inflammatory markers showed significantly lower C-reactive protein (CRP) levels in group NB at 24 h postoperatively. Hemodynamic monitoring results indicated that it had a minor impact. Conclusion We confirmed that the direct-vision intraoperative celiac plexus block is a safe and effective procedure that significantly reduces postoperative opioid consumption and pain scores. Further studies with larger sample sizes are warranted to confirm these findings and explore long-term outcomes. Trial registration Clinical Trial Registry Identifier: NCT05205720. Registered on January 25, 2022.

Erector spinae plane (ESP) block is a novel regional anesthesia technique and gaining importance for postoperative pain management. Since it was first described, the clinicians wonder if this new simple technique can replace paravertebral block (PVB). We aimed to compare the postoperative analgesic effect of ESP block and PVB with a control group in breast surgeries. Randomized controlled trial. Operating room. Seventy-five ASA I–II patients aged 25–65, who were scheduled to go under elective unilateral breast surgery for breast cancer were included to the study. Patients were randomized into three groups as ESP, PVB, and Control group. Ultrasound (US) guided ESP block and PVB with 20 ml 0.25% bupivacaine was done preoperatively to the patients according to their groups. All patients were provided with iv patient-controlled analgesia device for postoperative analgesia. Morphine consumptions and numeric rating scale (NRS) scores for pain were recorded at 1st, 6th, 12th and 24th hours postoperatively. There was a statistically significant difference between ESP and Control groups (p < 0,001) and between PVB and Control groups (p < 0,001), while there was no difference between ESP and PVB groups (p > 0,05) for 24-hour morphine consumptions. There was a significant difference between PVB and Control groups for NRS at postoperative 1st and 6th hour (p = 0.018 and p = 0.027 respectively). This study has shown that US guided ESP block and PVB provided adequate analgesia in patients undergoing breast surgery and have an opioid sparing effect by reducing morphine consumption. Clinical Trials Registry: NCT03480958. •ESP block provides effective analgesia in breast surgery.•ESP block has lower risk of complications compared to TPV block.•Both ESP block and TPV block have a similar analgesic effect in breast surgery.

BackgroundThe pectoral nerves (Pecs) block types I and II are novel techniques to block the pectoral, intercostobrachial, third to sixth intercostals, and the long thoracic nerves. They may provide good analgesia during and after breast surgery. Our study aimed to compare prospectively the quality of analgesia after modified radical mastectomy surgery using general anesthesia and Pecs blocks versus general anesthesia alone.MethodsOne hundred twenty adult female patients scheduled for elective unilateral modified radical mastectomy under general anesthesia were randomly allocated to receive either general anesthesia plus Pecs block (Pecs group, n = 60) or general anesthesia alone (control group, n = 60).ResultsStatistically significant lower visual analog scale pain scores were observed in the Pecs group than in the control group patients. Moreover, postoperative morphine consumption in the Pecs group was lower in the first 12 hours after surgery than in the control group. In addition, statistically significant lower intraoperative fentanyl consumption was observed in the Pecs group than in the control group. In the postanesthesia care unit, nausea and vomiting as well as sedation scores were lower in the Pecs group compared with the control group. Overall, postanesthesia care unit and hospital stays were shorter in the Pecs group than in the control group.ConclusionsThe combined Pecs I and II block is a simple, easy-to-learn technique that produces good analgesia for radical breast surgery.

Background and ObjectivesTruncal blocks have a place within multimodal analgesia techniques in abdominal surgery. The quadratus lumborum block is a new abdominal truncal block used for somatic analgesia of both the upper and lower abdomen. In this prospective, double-blind, randomized study, we aimed to compare quadratus lumborum block and transversus abdominis plane block in pediatric patients undergoing lower abdominal surgery.MethodsFifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery were randomized into 2 groups: transversus abdominis plane block and quadratus lumborum block. All blocks were performed under general anesthesia before surgery. Pain levels were assessed using an FLACC (Face, Legs, Activity, Cry, Consolability) scale.ResultsThe study included 50 patients, after excluding 3 patients who were not eligible. The number of patients who required analgesia in the first 24 hours postoperatively was significantly lower in the quadratus lumborum block group (P < 0.05). In the quadratus lumborum block group, the postoperative 30-minute and 1-, 2-, 4-, 6-, 12-, and 24-hour FLACC scores were lower compared with those of the transversus abdominis plane block group (P < 0.05). Parent satisfaction scores were higher in the quadratus lumborum block group (P < 0.05).ConclusionsThe results of this study showed that in pediatric patients undergoing unilateral inguinal hernia repair or orchiopexy the quadratus lumborum block provided longer and more effective postoperative analgesia compared with the transversus abdominis plane block.Clinical Trials Registration: The trial was registered prospectively at clinicaltrials.gov (NCT02715999).

BackgroundParavertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique.MethodsSubjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB.ResultsBoth pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI −3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI −1.2 to −0.1; p=0.0043). No block-related adverse events occurred in either group.ConclusionsPVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1–2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery.Trial registration number NCT03549234.

Background and objectiveAn ultrasound-guided anesthetic technique targeting the interspace between the popliteal artery and capsule of the posterior knee (iPACK) can provide posterior knee analgesia with preserved motor function after total knee arthroplasty (TKA). This study compared the peroneal nerve motor-sparing effects of iPACK block and tibial nerve block (TNB) when combined with local infiltration analgesia (LIA) and continuous adductor canal block (CACB).MethodsIn this study, 105 patients scheduled for elective TKA were randomized to receive proximal iPACK block (iPACK1), distal iPACK block (iPACK2), or TNB, along with spinal anesthesia, modified LIA, and CACB. The primary outcome was the incidence of common peroneal nerve (CPN) motor blockade. Secondary outcomes included CPN sensory function, tibial sensorimotor function, posterior knee pain, pain score, intravenous morphine requirement, timed up-and-go test, quadriceps muscle strength, range of motion, length of hospital stay, patient satisfaction, and adverse events.ResultsThe incidence of CPN motor blockade was significantly higher in the TNB group than in the iPACK1 (p=0.001) and iPACK2 (p=0.001) groups, but was not significant between the iPACK1 and iPACK2 groups (p=0.76). Tibial nerve motor function was more preserved in the iPACK1 and iPACK2 groups than in the TNB group (p<0.001 and p<0.001, respectively). Complete CPN and tibial sensorimotor blockade were not observed in the iPACK2 group. Posterior knee pain score was significantly higher in the iPACK1 group than in other groups during the 24-hour postoperative period (p=0.001).ConclusionsCompared with TNB, iPACK1 and iPACK2 preserved CPN and tibial nerve motor function to a greater extent. However, iPACK2 did not demonstrate complete CPN and tibial nerve motor blockade while maintaining effective posterior knee pain relief.Trial registration numberTCTR20180206002.

BackgroundDouble-jaw surgeries are known to be painful and to require opioids. Maxillary (V2) and mandibular (V3) nerves block could provide adequate pain management with minimal opioid-related side effects. Our main objective was to evaluate the analgesic effect of bilateral ultrasound-guided V2 and V3 combined nerves block in patients undergoing double-jaw orthognathic surgery.MethodsIn this single-blind, randomized control study, 50 patients were prospectively allocated to either bilateral ultrasound-guided V2 and V3 combined nerves block or intraoral infiltration of local anesthetic. Primary outcome was the cumulative oral morphine equivalent (OME) consumption assessed at postoperative day 1. Secondary outcomes were cumulative OME consumption and pain scores in recovery room and at postoperative day 2, intraoperative anesthetic consumption, and opioid-related side effects. Preoperative anxiety was investigated by the Amsterdam Preoperative Anxiety and Information Scale (APAIS).ResultsCompared with infiltration, ultrasound-guided regional anesthesia reduced cumulative OME consumption on day 1 (45.7±37.6 mg vs 25.5±19.8 mg, respectively, mean difference of −20.1 (95% CI −37.4 to −2.9) mg, p=0.023) and day 2 (64.5±60 mg vs 35.8±30.2 mg, respectively, mean difference of −28.7 (95% CI −55.9 to −1.43) mg, p=0.040). Interestingly, worst pain score and cumulative OME consumptions on day 2 were positively correlated with the APAIS (Pearson’s correlation coefficient of 0.42 (p=0.003) and 0.39 (p=0.006), respectively).ConclusionBilateral ultrasound-guided V2 and V3 combined nerves block reduces postoperative opioid consumption by about 50% in patients undergoing double-jaw surgery.Trial registration number NCT05351151.