Search

Background & Objective: The laparoscopic sleeve gastrectomy is a popular intervention in morbidly obese patient. Postoperative pain relief is a major challenging issue in this procedure with known adverse effects on the respiratory excursion and the ability to cough by the patient. Various analgesic protocols have been tries to conquer this pain. Vitamin C is a micronutrient, water soluble vitamin with antioxidant and antinociceptive actions. We assessed the effect of vitamin C when used as a component of the multimodal analgesic technique in this cohort of the patients. Methodology: After obtaining the ethical committee approval and trial registration, 50 patients scheduled for laparoscopic sleeve gastrectomy were enrolled in this study. The patients were randomly divided into two equal groups according to the study protocol. Group C received vitamin C 500 mg every 8 h for 5 days perioperatively, while Group N received placebo in the same fashion. The surgery was performed under routine general anesthesia. We monitored hemodynamic, VAS, rescue analgesia profile, and gastrointestinal side effects in the immediately after operation, and then at 1, 2, 4, 8, 12, and at 24 h postoperatively. The postoperative morphine consumption was noted as a primary objective of the study. Independent sample T test, Mann-Whitney test, chi square test or Kruskal Wallis test were utilized to detect statistical differences between the studied groups. P < 0.05 was considered significant. Results: Postoperative morphine consumption was lower in Group C than in Group N (16.36 ± 2.37 vs. 20 ± 4.13 mg, P = 0.001). The frequency of morphine was significantly lower in Group C than in Group N (P = 0.009). VAS was lower in Group C than Group N at 4, 8, and 12 h postoperatively (P = 0.02, 0.001, 0.001), while other parameters where comparable. Abbreviation: CBC: complete blood count; IRB: Institutional Research Board; LFTs: liver function tests; LSG: laparoscopic sleeve gastrectomy; MABP: mean arterial blood pressure; NMDA: N-methyl D-aspartate; OSAS: obstructive sleep apnea syndrome; PACTR: Pan African Clinical Trial Registry; PEEP: positive end expiratory pressure.; PFT: pulmonary function tests; RFTs: renal function tests; TFTs: thyroid function test; TOF: train of four; VAS: visual analogue score. Preregistration: Institutional Research Board, Mansoura Faculty of Medicine (IRB # R.20.02.738, Feb 15-2020). Pan African clinical trial registry (PACTR- 202003565796463, date of registration: March 02-2020). Conclusion: Vitamin C via its antioxidant, antinociceptive properties and NMDA-receptor antagonist action can be used as a part of multimodal analgesic techniques. Vitamin C acts as co-analgesic, improves postoperative pain profile, and reduces the needs for other analgesic modalities. Key words: Vitamin C; Analgesia; VAS; Pain; Sleeve Gastrectomy Citation: Aboelelea M, Abedelkhalek M, Mamoun M. Role of vitamin C in multimodal analgesia for sleeve gastrectomy: a prospective randomized controlled trial. Anaesth. pain intensive care 2023;27(1):82−88. DOI: 10.35975/apic.v27i1.2110 Received: October 02, 2022; Reviewed: October 25, 2022; Accepted: December 09, 2022

Background & objective: Low back pain is a common problem, especially in the young and middle-aged working people, and is often very resistant to the conventional management. We evaluated the impact of transcutaneous auricular vagus nerve stimulation (tVNS), applied in conjunction with an exercise treatment program, on disability in chronic low back pain patients. Methodology: The study was conducted from June to October 2022. Twenty-two patients aged 42.18 ± 9.91 y, with Numerical Pain Rating Scale (NPRS) score 5.64 ± 1.09 and Roland Morris Disability Questionnaire (RMDQ) score 10 ± 4.670, were randomly assigned to two groups. The control group received only exercise therapy (EXC group, n = 11), and the intervention group received exercise and tVNS therapy (EXC + tVNS group, n = 11). The primary outcome was RMDQ, measured before and after the intervention. Result: The mean RMDQ was significantly improved in both groups. In the intervention group the improvement was from 9.45 ± 4.44 to 2.18 ± 2.71 (P = 0.000), in the control group it was from 10.55 ± 5.05 to 2.36 ± 2.06 (P = 0.001). Inter-group comparison showed no significant difference. The effect size of the control group (2.12) was similar with the intervention group (1.98). Conclusion: Addition of 2-weeks tVNS to exercise therapy did not show superior effect on disability improvement compared to exercise only in chronic low back pain. Exercise alone was sufficient to improve the mean RMDQ. Abbreviations: CLBP: Chronic low back pain; EXC: Exercise; tVNS: Transcutaneous auricular vagus nerve stimulation; NPRS: Numerical pain rating scale; RMDQ: Roland Morris disability questionnaire Key words: Chronic low back pain; Disability; Exercise; Transcutaneous Auricular Vagus Nerve Stimulation Citation: Uzlifatin Y, Arfianti L, Wardhani IL, Hidayati HB, Melaniani S. Effect of transcutaneous auricular vagus nerve stimulation in addition to exercise on disability in chronic low back pain patients: a randomized controlled study. Anaesth. pain intensive care 2022;27(1):73−81; DOI: 10.35975/apic.v27i1.2084 Received: December 07, 2022; Reviewed: December 28, 2022; Accepted: January 11, 2022

Background & objective: Inter-scalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. Although, this method has its side-effects and possibly complications. Supra-scapular nerve block and axillary nerve block have also been used in upper limb procedures. We compared ISB with the blockade of supra-scapular and axillary nerves (called shoulder block) for postoperative analgesia after shoulder arthroscopic surgical operation under ultrasound guidance (USG) and nerve stimulators. Methodology: It was a prospective, randomized, comparative study. Results: The VAS pain scores at different times postoperatively were not significantly different between the ISB and ShB groups (P = t 0.071, 0.28, 0.378, 0.358, 0.451 at 2, 4, 8, 16, and 24 h respectively. VAS 0 was significantly difference (P = 0.029) but still the VAS score was less than 3, so no pain killers were given. Conclusion: Ultrasound guided supra-scapular and axillary nerve blocks ae equally effective as inter-scalene brachial plexus block for postoperative analgesia in shoulder arthroscopic surgery with less side-effects. Abbreviations: ANB: Axillary Nerve Block; ISB: Interscalene Block; MAC: Minimum OR: Operating Room; REC: Research Ethics Committee; ShB: Shoulder Block; SSB: Supra-scapular Nerve Block; VAS: Visual Analogue Scale Citation: Elbermway MS, Elshantory SF, Aly RM, Mahran MG. Comparison between supra-scapular nerve block combined with axillary nerve block and interscalene brachial plexus block for postoperative analgesia following shoulder arthroscopy. Anaesth. pain intensive care 2022;26(5):674−680; DOI: 10.35975/apic.v26i5.2026

Background: Different adjuvants have been introduced to enhance the quality of local anesthetics and reduce its adverse events. This study was directed to compare the anesthetic and analgesic properties of intrathecal hyperbaric bupivacaine when three different adjuvant drugs were added. Methodology: One hundred full-term parturients aged 18 to 40 years, scheduled for elective cesarean section, were randomly assigned to 4 groups. Each group received 12.5 mg of 0.5% hyperbaric bupivacaine combined with either 0.5 ml saline (Group-B), 25µg fentanyl (Group-F), 0.8 mg nalbuphine (Group-N) or 2 mg midazolam (Group-M). The outcomes included the postoperative effective analgesia time, the sensorimotor characteristics, postoperative VAS score, pethidine consumption, maternal complications, and neonatal Apgar score. Results: Earlier onset of sensory and motor block was observed in Group F and N than in Group B and M. Duration of postoperative effective analgesia was longer in Groups F, N and M (252.42 ± 46.11, 227.34 ± 36.54 and 243.71 ± 44.95 hours, respectively) than in Group B (172.11 ± 20.99) (P < 0.001). VAS scores decreased in adjuvant groups during the first 12 hours postoperative and required pethidine doses were less. Conclusion: Addition of adjuvant agents to intrathecal bupivacaine improved the quality of subarachnoid block without increasing side-effects. Intrathecal midazolam provided comparable outcomes as the frequently used opioids. Abbreviations: CS: Cesarean section; LA: Local anesthetics; SA: Spinal anesthesia Key words: Intrathecal; Nalbuphine; Midazolam; Fentanyl; Postoperative analgesia; Cesarean section. Citation: Amin SR, Souidan I, Abdelzaam EM. Intrathecal midazolam is a comparable alternative to fentanyl and nalbuphine as adjuvant to bupivacaine in spinal anesthesia for elective cesarean section: a randomized controlled double-blind trial. Anaesth. pain intensive care 2022;27(1):89−96; DOI: 10.35975/apic.v27i1.1923 Received: June 26, 2022; Reviewed: November 28, 2022; Accepted: December 14, 2022

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech®, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management. Abbreviations: BUN: blood urea nitrogen; BSA: Body surface area; Cr: Creatinine; OR: Operating room; SJS: Stevens-Johnson Syndrome; TEN: Toxic epidermal necrolysis Key words: Anesthesia; COVID-19; Toxic epidermal necrolysis; Vaccine Citation: Bilge B, Erkilic E, İlhan G, Akin M, Kanbak O. Anesthetic management of toxic epidermal necrolysis: a report of two cases. Anaesth. pain intensive care 2022;27(1):135−138; DOI: 10.35975/apic.v27i1.2113 Received: November 22, 2022; Reviewed: November 29, 2022; Accepted: December 02, 2022

OBJECTIVE: This study aimed to evaluate the long-term effects of spinal cord stimulation (SCS) in patients with painful diabetic polyneuropathy (PDPN).MATERIALS AND METHODS: This prospective cohort study was the eight-to-ten-year follow-up of a previously performed pilot and randomized controlled trial on the effects of SCS in PDPN, initiated by the multidisciplinary pain center of Maastricht University Medical Center+. The study population consisted of a subgroup of patients who still used SCS treatment ≥ eight years after implantation (n = 19). Pain intensity scores (numeric rating scale [NRS]) during the day and night and data on secondary outcomes (ie, quality of life, depression, sleep quality) were reported during yearly follow-up consultations. Long-term efficacy of SCS was analyzed by comparing the most recently obtained data eight to ten years after implantation with those obtained at baseline.RESULTS: Pain intensity, day and night, was significantly (p < 0.01) reduced by 2.3 (NRS 6.6-4.3) and 2.2 (NRS 6.8-4.6) points, respectively, when comparing the long-term data with baseline. Moreover, for > 50% of patients, the pain reduction was > 30%, which is considered clinically meaningful. No differences were found regarding the secondary outcomes.CONCLUSION: This eight-to-ten-year follow-up study indicates that SCS can remain an effective treatment in the long term to reduce pain intensity in a subcohort of patients with PDPN who still had an SCS device implanted after eight years.

Background: End-stage liver disease (ESLD) patients carry heavy symptom burdens and risk receiving aggressive and sometimes unwanted care at end of life. Palliative care (PC), which aims to alleviate symptoms and facilitate goal-concordant care in serious illness, may offer substantial benefits for ESLD patients but is not widely provided. Objectives: To assess the impact of PC integrated within hepatology (PCIH) services on health care utilization, advance care planning (ACP), and hospice enrollment. Design: We compared patients who received PCIH (n = 55) to a retrospective cohort (n = 57) receiving usual care in an outpatient hepatology clinic. Setting/Subjects: From June 2016 to November 2017, we enrolled patients receiving care in a U.S. public hospital clinic who met the following inclusion criteria: (1) ESLD with a Model for End-Stage Liver Disease score ≥20, (2) hepatology approval for PC referral, and (3) at least one advanced complication of ESLD. Measurements: We assessed patient demographics, clinical information, health care insurance status, health care utilization, completion of psychosocial assessments, and ACP using two-sided Fisher's exact test and Mann-Whitney U tests. Results: Patients receiving PCIH more frequently had goals of care discussions (87.3% vs. 21.2% p ≤ 0.01), completed ACP documentation (56.4% vs. 7.0%, p ≤ 0.01), psychosocial assessments (98.2% vs. 35.1%, p ≤ 0.01), and hospice enrollment (25.5% vs. 7.0%, p = 0.01). Patients receiving PCIH who were hospitalized also had fewer mean hospitalization days (13 vs. 19.7 days, p ≤ 0.01). Conclusions: Embedding PC services in a hepatology clinic is a promising strategy to improve care for ESLD patients in public hospitals.

Background: According to previous research, 20% of infants experience prolonged postsurgical pain 6–12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries.Methods: Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia.Results: The FLACC score 2 h post¬operatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups.Conclusions: The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery.

Background: A precise anatomical understanding of the adductor canal (AC) and its neural components is essential for discerning the action mechanism of the AC block. We therefore aimed to clarify the detailed anatomy of the AC using micro-computed tomography (micro-CT), histological evaluation, and immunofluorescence (IF) assays.Methods: Gross dissections of 39 thighs provided morphometric data relevant to injection landmarks. Serial sectional images of the AC were defined using micro-CT and ultrasonography. The fascial and neural structures of the AC proper were histologically evaluated using Masson’s trichrome and Verhoeff-Van Gieson staining, and double IF staining using choline acetyltransferase (ChAT) and neurofilament 200 antibodies.Results: The posteromedial branch insertion of the nerve to vastus medialis (NVM) into the lateral border of the AC proper was lower (14.5 ± 2.4 cm [mean ± SD] above the base of the patella) than the origin of the proximal AC. The AC consists of a thin subsartorial fascia in the proximal region and a thick aponeurosis-like vastoadductor membrane in the distal region. In the proximal AC, the posteromedial branch of the NVM (pmNVM) consistently contained both sensory and motor fibers, and more ChAT-positive fibers were observed than in the saphenous nerve (27.5 ± 11.2 / 104 vs. 4.2 ± 2.6 / 104 [counts/µm2], P < 0.001).Conclusions: Anatomical differences in fascial structures between the proximal and distal AC and a mixed neural component of the neighboring pmNVM have been visualized using micro-CT images, histological evaluation, and IF assays.

Purpose of reviewIn 1989, the United Nations passed the 'Convention on the Rights of the Child' (UNCRC) and, among others claimed the highest attainable standard of health for children and consequently the highest level of safety and quality in paediatric anaesthesia. SAFETOTS (Safe Anesthesia For Every Tot, www.safetots.org), an initiative of international active paediatric anaesthetists, has derived 10 rights, the '10 R' of children undergoing anaesthesia care, which are critical for the well being of the child.Recent findingsThe current situation in paediatric anaesthesia care in Europe does not always meet the requirements demanded by the UNCRC. Anaesthesia-related complications in children are still persistent. Anaesthesiologists are frequently asked to provide care for newborns, infants and small children without having sufficient child-specific expertise, resulting in an increased morbidity and mortality.SummaryThis article will explain these statutes of children's rights and their implications for everyday paediatric anaesthesia. Furthermore, it will also express the institutional and political changes that are needed to guarantee children their right to enjoy the highest attainable standard of health.