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Introduction: Pneumothoraces are frequently treated by emergency physicians. Tube thoracostomy, the definitive treatment for a spontaneous pneumothorax, is associated with significant pain. Analgesia prior to tube thoracostomy often involves the administration of opioids and local infiltration of anesthetics. Thus far, regional anesthesia prior to pigtail tube thoracostomy in the emergency department (ED) has not been well described; it offers promise in alleviating pain associated with this procedure. Due to its ability to anesthetize all or most of the structures associated with tube thoracostomy—skin, serratus anterior muscles, intercostal muscles, and the parietal pleura—the serratus anterior plane block (SAPB) is a potentially promising fascial plane block prior to pigtail tube thoracostomy.Case Series: We present three cases of patients in the ED who received a SAPB and had nearly complete or complete anesthesia during pigtail tube thoracostomy.Conclusion: Pigtail tube thoracostomies are commonly performed in the ED and can be associated with significant pain despite a multimodal approach to pain management. The SAPB offers a safe and effective approach to anesthesia for patients in the ED undergoing a pigtail tube thoracostomy.

Introduction: Emergency physicians frequently manage anterior shoulder dislocations (ASD). While there are many effective methods to reduce an ASD, adequate analgesia is imperative.Case Series: We used the supraclavicular brachial plexus (SBP) block to reduce ASD in three patients.Conclusion: The SBP block reliably anesthetizes the entire upper extremity, including the shoulder, by targeting all trunks and divisions of the brachial plexus. Complications are rare. Considering its ease of implementation and paucity of complications, the SBP block may be an effective means for reducing ASD.

Introduction: Lower extremity injuries are commonly evaluated and treated in the emergency department (ED). Pain management for these injuries often consists of acetaminophen, non-steroidal anti-inflammatories, and opioids. Despite this treatment regimen, adequate analgesia is not always achieved.Case Report: A 38-year-old man presented to the ED with a non-displaced tibia-fibula fracture. The patient did not attain analgesia with intravenous medications but did get complete anesthesia of his lower leg with a combination saphenous and popliteal sciatic nerve block.Conclusion: Emergency physicians possess the skill set required to effectively perform a saphenous and popliteal sciatic nerve block and should consider adding this procedure to their armamentarium of pain management techniques in treating injuries distal to the knee.

Introduction: Readiness to perform a wide variety of procedures or manage nearly any patient presentation remains an essential aspect of emergency medicine training and practice. Often, simulation is needed to supplement real-life exposure to provide comfort and knowledge, particularly with rarer pathology and procedures. As the scope of practice continues to grow, newer procedures, such as ultrasound (US)-guided nerve blocks (UGNB), are becoming integrated into resident training, building on previously established skills. The fascia iliaca compartment block (FICB) is performed on patients with specific femoral fractures and is a now a component of standard multimodal pain regimens, with US-guidance limiting adverse events. Given the need for high volumes of local anesthetic to perform the block it is imperative for clinicians to understand dosing as well as recognize and treat local anesthetic systemic toxicity (LAST). With sparse literature on sequential immersive and procedural simulation involving intertwined topics, this presents a unique opportunity for learners.Methods: To study the perceived knowledge and comfort with FICB and LAST, a pilot study was developed with two separate but concurrent one-hour simulations completed encompassing one of each topic over one day. We surveyed 19 learners, consisting of residents ranging from postgraduate years 1–3, prior to and immediately following completion, regarding their perceptions. We used the Stuart-Maxwell test to compare survey data.Results: More than half of participants (56%) had not received prior formal training on FICB. There was a positive trend in perceived confidence and knowledge with visualizing relevant anatomy (4.0 [2.0–6.0] vs 9.0 [7.5–10.0], P = 0.10), performing FICB (4.0 [1.0–5.0] vs 9.0 [7.0–10.0, P = 0.08]), and perceived ability to teach their peers (3.0 [1.0–5.0] vs 8.5 [7.0–10.0], P = 0.20). Perceived ability in diagnosing and managing LAST also increased following the simulation (5.0 [3.0–6.0] vs 6.0 [6.0–7.0], P = 0.12 and 3.0 [2.0–6.0] vs 6.0 [6.0–7.0], P = 0.08, respectively).Conclusion: Learners’ perceptions of this simulation experience echo the findings of previous studies in which simulation can be used to teach procedures and pathology; of note, however, we presented a novel experience with a combination of immersive and procedural simulation.

PURPOSE: The pupil displays chaotic oscillations, also referred to as pupillary unrest in ambient light (PUAL). As pain has previously been shown to increase pupillary unrest, the quantitative assessment of PUAL has been considered a possible tool to identify and quantify pain. Nevertheless, PUAL is affected by various states, such as vigilance, cognitive load, or emotional arousal, independent of pain. Furthermore, systematically applied opioids are known to reduce PUAL, thus potentially limiting its usefulness to detect pain or changes in pain intensity. To test the hypothesis that PUAL can reliably identify changes in pain intensity in a clinical setting, we measured PUAL in patients experiencing substantial pain relief when regional anesthesia interventions were applied after surgery. METHODS: We conducted an observational study at an academic surgery centre following institutional review board approval. Eighteen patients with unsatisfactory pain control following surgery underwent regional anesthesia procedures to improve pain control. We used infrared pupillometry to assess pupillary unrest before and after the regional block. We then compared the changes in pupillary unrest with the changes in pain scores (numeric rating scale [NRS], range 0-10). RESULTS: Eighteen patients received epidural anesthesia (n = 14) or peripheral nerve blocks (n = 4), resulting in improvement of mean (standard deviation [SD]) NRS pain scores from 7.2 (1.7) to 1.9 (1.8) (difference in means, -2.2; 95% confidence interval [CI], -6.3 to -4.1; P

Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including nonliposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of this study was to compare pain control and opioid consumption within 48 hours postoperation in those undergoing TSA with either LIB or NLIB. This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or an NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day emergency department (ED) visits or readmissions. The primary outcome was postoperative pain and opioid use. Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (P >.05 for all). However, the LIB group had improved pain scores at 24 and 36 hours postoperation (P <.05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 numeric rating scale–11 score, between the 2 anesthesia groups after adjusting for preoperative pain and baseline opioid use (odds ratio 1.25, 95% confidence interval 0.57-2.74; P =.57). Overall, 99 of 316 patients receiving LIB (31.3%) did not require any postoperative opioids compared with 38 of 173 receiving NLIB (22.0%); however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (P =.33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (P >.05 for both). Finally, no significant differences were found in 30- and 90-day ED visits or readmission rates (all P >.05). LIB and NLIB demonstrated differences in patient-reported pain scores at 24 and 36 hours postoperation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents, and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates. [ABSTRACT FROM AUTHOR]

Purpose of Review: Hip surgeries are commonly associated with significant postoperative pain, which can hinder early mobilization, prolong hospital stays, and increase healthcare costs. Effective pain management in this patient population is crucial to improving outcomes and reducing complications. Recent Findings: Traditional pain control methods, such as systemic opioids, are often associated with adverse effects, including respiratory depression, nausea, and delayed recovery. Regional anesthesia techniques, particularly the suprainguinal fascia iliaca block (SFIB), have gained attention for the potential to provide targeted, long-lasting analgesia with fewer systemic side effects. Conclusion: This narrative review evaluates efficacy of the SFIB, an effective and safe technique for postoperative pain management in hip surgeries. The fascia iliaca block, initially described as a low-volume alternative to the lumbar plexus block, has evolved, with the suprainguinal approach demonstrating particular promise. By accessing the lumbar plexus and blocking the femoral, obturator, and lateral femoral cutaneous nerves, the SIFIB provides broad analgesia to the hip region. Recent studies have highlighted that, compared to traditional infrainguinal approaches, the suprainguinal technique offers superior spread and more consistent pain control related to its targeted proximity to the inguinal ligament. Consequently, this technique may optimize perioperative pain management and improve functional recovery in patients undergoing hip surgeries. [ABSTRACT FROM AUTHOR]

Lumbar plexus block (LPB) and sacral plexus block (SPB) are commonly used regional anesthesia techniques for lower limb surgeries. We propose a novel approach combining anterior LPB and lateral SPB in a semi-lateral supine position with a pad under the upper body. This approach minimizes discomfort and pain during position changes, enhances probe manipulation space, and aids in maintaining aseptic conditions throughout the entire operation. In a study involving 9 elderly patients undergoing hip surgery for femoral neck fractures, we used this modified anterior LPB and lateral SPB technique. Prior to the regional anesthesia, patients were sedated with dexmedetomidine, and the lumbar plexus and sacral plexus were localized using dual guidance techinques, including ultrasound and electrical nerve stimulation. This case series demonstrates the effectiveness of the modified approach, significantly minimizing pain and discomfort associated with positional changes, and is a promising modification to the classical approach. Trial registration number: NCT05901415. [ABSTRACT FROM AUTHOR]

Background: Despite known disparities in pediatric perioperative outcomes, few studies have examined factors associated with the use of regional anesthesia for pediatric orthopedic surgery. Aims: This investigation aimed to determine if minority and developmental disability status were associated with the allocation of peripheral nerve blocks in calcaneal osteotomy. Methods: We conducted a single‐center, retrospective study of records of patients <18 years who underwent calcaneal osteotomy from 2013 to 2023. Regional technique was classified into three groups: popliteal‐sciatic single‐shot block, popliteal‐sciatic catheter, and no block. Patients were classified as either nonminority (white, non‐Hispanic) or minority. Developmental disability status was defined based on medical history and classified as binary. Anesthesiologists were classified as "regional" or "nonregional" based on clinical expertise. A Bayesian hierarchical multinomial model with random intercepts for patients and surgeons was used to investigate the association of minority status, developmental disability, and anesthesiologist expertise with block selection. Results: We analyzed 287 cases in 225 patients; of these, 55% occurred in minority patients and 28% occurred in patients with developmental disability. Catheters were placed in 45% of cases, single shot blocks in 41%, and no block in 14%. Minority and nonminority patients had a similar likelihood of receiving of any block. Patients with developmental disability had a −22% absolute difference of receiving any block (95% credible interval [−38%, −7%]) compared to those without developmental disability (55% vs. 77%), an effect primarily driven by a lower rate of catheter placement in these children. Regional anesthesiologists were more likely to place catheters (23% absolute increase; 36% vs. 13%) and more likely to perform any block in children with developmental disability (30% absolute increase; 67% vs. 37%) than nonregional anesthesiologists. Conclusions: Decision‐making surrounding the placement of regional anesthesia techniques is complex. In this study, developmental disability status and anesthesiologist experience were associated with a difference in the use of regional anesthesia in patients undergoing calcaneal osteotomy. [ABSTRACT FROM AUTHOR]

This single-center study explored the efficacy of superficial parasternal intercostal plane block (SPIPB) versus erector spinae plane block (ESPB) in opioid-sparing within Nociception Level (NOL) index-directed anesthesia for elective open-heart surgery. After targeted propensity matching, 19 adult patients given general anesthesia with preincisional SPIPB were compared to 33 with preincisional ESPB. We hypothesized that SPIPB is non-inferior to ESPB in reducing total intraoperative fentanyl consumption, with a non-inferiority margin (δ) set at 0.1 mg. Intraoperative fentanyl dosing targeted a NOL index ≤ 25. Postoperatively, paracetamol 1 g 6-hourly and morphine for numeric rating scale (NRS) ≥ 4 were administered. This study could not demonstrate that SPIPB was inferior to ESPB for total intraoperative fentanyl consumption, as the confidence interval for the median difference of 0.1 mg (95% CI 0.05–0.15) crossed the predefined δ, with the lower bound falling below and the upper bound exceeding δ, p = 0.558. SPIPB led to higher postoperative morphine use at 24 and 48 h: 0 (0–40.6) vs. 59.5 (28.5–96.1) µg kg−1, p < 0.001 and 22.2 (0–42.6) vs. 63.5 (28.5–96.1) µg kg−1, p = 0.001. Four times fewer SPIPB patients remained morphine-free at 48 h, p < 0.001, and their time to first morphine dose was three times shorter compared to ESPB patients, p = 0.001. SPIPB led to higher time-weighted average NRS scores at rest, 1 (0–1) vs. 1 (1–2), p = 0.004, and with movement, 2 (1–2) vs. 3 (2–3), p = 0.002, calculated over the 48-h period post-extubation. The SPIPB group had a significantly higher average NOL index, p = 0.003, and greater NOL index variability, p = 0.027. This study could not demonstrate that SPIPB was inferior to ESPB for intraoperative fentanyl consumption. Significant differences were observed in secondary outcomes, with SPIPB leading to higher postoperative morphine use, higher pain scores, and reduced nociception control. [ABSTRACT FROM AUTHOR]

The high frequency variability index (HFVI)/analgesia nociception index (ANI) is purported to assess the balance between nociception and analgesia in patients under general anesthesia. This observational study investigated whether intraoperative HFVI/ANI correlates with postoperative pain in patients performed with nerve block under general anesthesia in video/robotic-assisted thoracoscopic surgery (VATS/RATS). We investigated whether maximum postoperative pain at rest and postoperative morphine consumption are associated with HFVI/ANI just before extubation, mean HFVI/ANI during anesthesia, the difference in HFVI/ANI between before and 5 min after the start of surgery, and the difference in HFVI/ANI between before and 5 min after the nerve block. Data obtained from 48 patients were analyzed. We found no significant association between HFVI/ANI just before extubation and postoperative Numerical Rating Scale (NRS) score. Receiver operating characteristic curve analysis revealed that moderate (NRS > 3) or severe (NRS > 7) postoperative pain could not be predicted by HFVI/ANI just before extubation. In addition, there were no associations between postoperative morphine consumption and HFVI/ANI at any time points. The present study demonstrated that it is difficult to predict the degree of postoperative pain in patients undergoing VATS/RATS under general anesthesia combined with peripheral nerve block, by using HFVI/ANI obtained at multiple time points during general anesthesia. [ABSTRACT FROM AUTHOR]

Background: Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time. Methods: This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions. Results: Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%–9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%–6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%. Conclusion: The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology. [ABSTRACT FROM AUTHOR]

Introduction: Regional anesthesia increases in popularity in orthopaedic surgery. It is usually applied in elective surgeries of the extremities. The aim of this study was to assess indication of the use of general anesthesia in the surgical treatment of distal radius fractures. Methods: Patients undergoing surgical fixation for distal radius fractures between January 1st, 2020, and December 31st, 2021, were included. Exclusion criteria encompassed incomplete 12-month follow-up, transferred or multiply injured patients, those with prior upper limb fractures, or admission for revision surgeries. Patients were categorized by anesthesia type: GA or plexus block anesthesia (PA). Primary outcomes comprised tourniquet utilization and duration of surgery, while secondary outcomes encompassed complications (e.g., complex regional pain syndrome [CRPS], local wound infection, implant removal necessity) and range of motion at three, six, and twelve months post-surgery. Fractures were classified using the AO/OTA system. Results: The study enrolled 127 patients, with 90 (70.9%) in Group GA and 37 (29.1%) in Group PA. Mean patient age was 56.95 (± 18.59) years, with comparable demographics and fracture distribution between groups. Group GA exhibited higher tourniquet usage (96.7% vs. 83.8%, p = 0.029) and longer surgery durations (85.17 ± 37.8 min vs. 65.0 ± 23.0 min, p = 0.013). Complication rates were comparable, Group GA 12.2% versus Group PA 5.4% p = 0.407, OR 2.44; 95%CI 0.51 to 11.58, p = 0.343). Short-term functional outcomes favored Group PA at three months (e.g., Pronation: 81.1° ± 13.6 vs. 74.3° ± 17.5, p = 0.046). Conclusion: Solely classifying distal radius fractures does not dictate anesthesia choice. Complexity of injury, anticipated surgery duration, less use of tourniquet, and rehabilitation duration may guide regional anesthesia utilization over GA in distal radius fracture fixation. [ABSTRACT FROM AUTHOR]

Background: Thoracic outlet syndrome (TOS) is an uncommon condition defined by the compression of neurovascular structures within the thoracic outlet. When conservative management strategies fail to alleviate symptoms, surgical decompression becomes necessary. The purpose of this study is to evaluate and compare the efficacy and safety of regional anesthesia (RA) using spontaneous breathing in contrast to general anesthesia (GA) for patients undergoing surgical intervention for TOS. Methods: We conducted a retrospective comparative study involving 68 patients who underwent trans-axillary first rib resection for TOS. The patient cohort was divided into two groups: 29 patients in the GA group and 39 patients in the RA group. The RA technique employed consisted of supraclavicular brachial plexus (SBP) and pectoral nerve (PECS II) blocks, accompanied by deep sedation. Key outcome measures such as pain scores, opioid consumption, and various perioperative parameters were systematically analyzed. Results: Postoperative pain levels recorded in the recovery room were significantly lower in the RA group, with a median numerical rating scale (NRS) score of zero compared to two in the GA group (p = 0.0443). Additionally, both intraoperative and postoperative opioid consumption showed a marked reduction in the RA group, with p-values of less than 0.001 and 0.0418, respectively. The RA approach was associated with shorter surgical durations (p = 0.0008), a decrease in the incidence of postoperative nausea and vomiting (PONV) (p = 0.0312), and a lower occurrence of intraoperative lung injuries (p < 0.0001). Furthermore, the length of hospital stay was significantly reduced for patients in the RA group. Conclusions: Although both groups reported low postoperative pain scores, the regional anesthesia approach exhibited distinct advantages in terms of opioid consumption, surgical duration, and overall perioperative outcomes. The utilization of SBP and PECS II blocks facilitated surgical procedures and mitigated complications, thereby positively influencing the postoperative recovery trajectory. Future prospective studies are essential to validate these findings further and to investigate long-term outcomes associated with the use of regional anesthesia in TOS surgery. [ABSTRACT FROM AUTHOR]

Background: The integration of ultrasound technology in regional anesthesia has transformed procedural approaches, yet comprehensive comparisons with traditional landmark-based techniques remain essential for evidence-based practice. Methods: This prospective, randomized controlled trial compared ultrasound-guided versus landmark-based techniques for regional anesthesia in 240 patients (120 per group) undergoing upper and lower limb surgery. Primary outcomes included block success rates and complications. Results: Block success rates were significantly higher in the ultrasound-guided group (95.0% vs 81.7%, p<0.001). Procedure duration was shorter with ultrasound guidance (8.4 ± 2.3 vs 12.7 ± 3.6 minutes, p<0.001), requiring fewer needle passes (median 1 vs 3, p<0.001). Local anesthetic volume requirements were reduced (22.4 ± 3.2 vs 28.6 ± 4.1 mL, p<0.001). Complications were significantly lower in the ultrasound group, including vascular puncture (1.7% vs 6.7%, p=0.032) and neurological symptoms (1.7% vs 5.8%, p=0.038). Conclusions: Ultrasound guidance significantly improves the success rate and safety profile of regional anesthesia procedures while reducing procedure time and local anesthetic requirements. [ABSTRACT FROM AUTHOR]

Background: Postoperative pain management is crucial for patient comfort and recovery after shoulder surgery. Suprascapular nerve block (SSNB) has been proposed as a regional anesthetic technique for postoperative analgesia in shoulder surgery patients. Objectives: To evaluate the efficacy and safety of suprascapular nerve block for postoperative pain relief in patients undergoing shoulder surgery. Methods: A prospective, randomized, placebo-controlled, double-blind study was conducted involving 72 patients (aged 18-60 years, ASA I-II) undergoing elective shoulder surgery. Patients were randomized to receive either SSNB with 10 mL of 0.5% bupivacaine (n=36) or placebo with 10 mL of 0.9% NaCl (n=36). Pain scores (Numerical Rating Scale, NRS) and tramadol consumption were assessed at 0, 6, 12, 18, and 24 hours postoperatively. Adverse events were recorded. Results: Pain scores were significantly lower in the SSNB group compared to the placebo group at 0 hours (median NRS: 0 vs. 3, p<0.001), 6 hours (median NRS: 2 vs. 5, p<0.001), and 24 hours (median NRS: 2 vs. 5, p<0.001). The mean tramadol consumption in 24 hours was significantly lower in the SSNB group (124.17 ± 62.67 mg) compared to the placebo group (309.17 ± 88.01 mg) (p=0.048). No significant adverse events were reported. Conclusion: Suprascapular nerve block is an effective and safe technique for postoperative pain relief in patients undergoing shoulder surgery, providing superior analgesia and reduced opioid consumption compared to placebo in the first 24 hours after surgery. [ABSTRACT FROM AUTHOR]

The anesthesia for elderly patients presents various challenges arising from physiological changes accompanying aging, pre-existing disease conditions and susceptibility to POCD. This paper thus aims to discuss measures of preventing complications that range from individualizing anesthetic regimens, modifying the doses of drugs used to conducting preoperative evaluations. Pharmacokinetics and pharmacodynamics are affected by aging, and they also need an individual approach to anesthesia. The advantages of regional anesthesia in situations where frail patients are involved involve concerns that hold merit and specifically pertain to the issue of the systemic effects although outcome difference is still a matter that has not been definitively determined. The role of surgery in disease treatment makes the proposition of a complex, integrated model of surgical care essential. More investigations should be directed to evaluate the dose-response and differential concentration effects of various agents used in different anesthesia protocols for elderly patients, determine the effect of anesthesia on cognitive function and memory, and compare the efficacy of using regional versus general anesthesia in elderly patients. [ABSTRACT FROM AUTHOR]

Background: Effective pain management is a crucial aspect of postoperative care for minimally invasive surgeries, such as laparoscopic nephrectomy. Regional anesthesia techniques like the transmuscular quadratus lumborum block (TMQLB) and thoracic paravertebral block (TPVB) have gained attention as part of multimodal analgesia strategies aimed at minimizing opioid use and enhancing recovery. While TPVB is a well-established technique, TMQLB has emerged as a promising alternative due to its ease of administration and potential for broader sensory coverage. This study aimed to compare the analgesic efficacy, opioid-sparing effects, and postoperative recovery outcomes of TMQLB and TPVB in patients undergoing laparoscopic nephrectomy through a prospective randomized controlled trial. Materials and Methods: This prospective, randomized, double-blind, single-center study was conducted to compare the analgesic efficacy and recovery outcomes of transmuscular quadratus lumborum block (TMQLB) and thoracic paravertebral block (TPVB) in laparoscopic nephrectomy patients. A total of 68 participants, aged 17-80 years and classified as ASA I-III, were enrolled and randomized into two groups. All blocks were performed under ultrasound guidance using 0.5% ropivacaine at a dose of 0.4 ml/kg. The primary outcome was 48-hour postoperative cumulative morphine consumption, while secondary outcomes included sensory block dermatomes, intraoperative hemodynamic changes, Numerical Rating Scale (NRS) pain scores, postoperative recovery data, and quality of recovery scores. Data analysis was performed using GraphPad software, with a significance threshold of p < 0.05. Results: A total of 68 patients were randomized into two groups (n=34 each), with 30 patients per group included in the final analysis. Both groups had similar baseline characteristics. Postoperative cumulative morphine consumption was significantly lower in the TPVB group at all time points (p < 0.05), though pain scores were comparable. The postoperative pain NRS at rest and on movement, incidences of side effects, anesthesia-related satisfaction, and quality of recovery scores were similar between the two groups (all P > 0.05). The TMQLB group achieved a broader sensory block (p = 0.002). Intraoperative hemodynamics were stable, with no significant differences between groups. The TMQLB group required more sevoflurane and fentanyl. Postoperative recovery, including gas passing, urination, mobilization, and length of stay, showed no significant differences. Complication rates and quality of recovery were similar, with high patient satisfaction in both groups. Conclusion: The present study demonstrated that transmuscular quadratus lumborum block (TMQLB) provides a comparable postoperative analgesic effect to T10-level thoracic paravertebral block (TPVB), as reflected by similar 48-hour cumulative morphine consumption in patients undergoing laparoscopic partial nephrectomy. TMQLB shows promise as a viable alternative to TPVB in select surgical settings and patient populations, warranting further research to explore its potential applications and benefits. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess whether parasternal block with multihole catheters inserted before surgical incision enables to alleviate postoperative analgesia and opioid reduction in cardiac surgery patients with sternotomy. Methods: Twenty-six adult patients scheduled for cardiac surgery with sternotomy aged between 18 and 84 olds were included in this prospective, monocentric, open, single-group trial. Two parasternal multihole catheters were inserted on each side of the sternum before the surgical skin incision for cardiac surgery and 10 mL of ropivacaine 7.5 mg mL–1 was initially administered in each catheter. Local anesthetic administration followed by continued infusion at 3 mL hr–1 of ropivacaine 2 mg mL–1 per catheter for 48 h postoperatively upon patient arrival in the intensive care unit. The efficacy of the parasternal block was assessed according to a composite endpoint including pain score at rest, pain score during movements (dynamic pain), and morphine consumption over 48 hours. Results: The treatment failed in 11 patients and was considered effective in 15 patients. Sixteen patients out of 26 had a sternal pain score ≤≤3/10 on more than 75% of observations, and the treatment was considered successful. In 23/26 patients (88%), the mean pain score at cough was ≤≤3.5/10 and the treatment was considered successful. Morphine consumption over 48 h was significantly lower in the intervention group compared to the control group 7 mg [6; 21] versus 142 mg [116; 176] (P < 0.001). Conclusions: Parasternal block with multihole catheters inserted before the surgical incision is an effective technique for postoperative analgesia and opioid reduction. [ABSTRACT FROM AUTHOR]

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed. [ABSTRACT FROM AUTHOR]

The muscular dystrophies or muscle-wasting diseases include a diverse group of genetic disorders, which result in progressive degeneration of skeletal muscles, progressive muscle weakness, and comorbid multi-system involvement. Duchenne muscle dystrophy is the most common type of muscular dystrophy with a reported incidence of 1 in every 3500–6000 male live births in the United States. Given the progressive nature of these disorders, skeletal muscle weakness frequently progresses to loss of the ability to ambulate and perform functions of daily life. In addition to affecting the skeletal musculature, many muscular dystrophies have effects on both cardiac and smooth muscles. As respiratory muscles are one of the most frequently affected muscles in patients with muscular dystrophies, progressive respiratory insufficiency may occur with dependance on non-invasive forms of respiratory support. Given the progressive multi-system involvement associated with the muscular dystrophies, perioperative care and the use of general anesthetic agents and opioids may result in postoperative respiratory failure. In an effort to avoid the deleterious effects of anesthetic agents and opioids on hemodynamic and respiratory functions, regional anesthesia may be used as an adjunct to or instead of general anesthesia. This manuscript provides a literature review and educational summary regarding the use of regional anesthetic techniques in pediatric-aged patients with muscular dystrophies. [ABSTRACT FROM AUTHOR]

Regional anesthesia has become an integral component of postoperative analgesia and multimodal analgesia during surgery, providing opioid sparing effects and maintaining a beneficial adverse effect profile. Although neuraxial techniques were initially the primary techniques used for intraoperative and postoperative anesthesia and analgesia, many of these techniques have been replaced by selective nerve blockade. This has been facilitated by the widespread use of ultrasound-guided over conventional landmark techniques. Fascia iliaca compartment blockade (FICB) is performed by depositing a local anesthetic agent underneath the FI fascial sheath which lies on top of the iliopsoas muscle. With the landmark technique, the FICB is more commonly applied using an approach below the inguinal ligament. Advancements in the use of ultrasound have led to development of a potentially superior suprainguinal fascia iliaca (SIFI) block for hip and thigh surgery. An improved cephalad distribution of the local anesthetic solution within the fascia iliaca compartment and comparable analgesic efficacy compared to the more invasive lumbar plexus block has resulted in increased use of the SIFI block in both adults and pediatric-aged patients. The SIFI block aims to target the femoral nerve (FN), lateral femoral cutaneous nerve (LFCN), and obturator nerve (ON), thus providing analgesic coverage for hip, femur, and thigh surgery. Although the FN and LFCN are reported to be consistently blocked by the suprainguinal approach, blockade of the ON may be less reliable and requires a higher volume of the local anesthetic agent, proving this technique to be a volume-dependent block. A lower volume of local anesthetic solution may be associated with block failure, especially in the area supplied by the ON and less frequently in the distribution of the LFCN. Thus, local anesthetic concentration must be adjusted in smaller children and infants to maintain effective volume while not exceeding local anesthetic dosing limitations. The current manuscript reviews the innervation of the lower extremity including the anatomy of the fascia iliaca compartment, outlines different approaches for the fascia iliaca block, and reviews the current practice of SIFI blockade in adults and children. [ABSTRACT FROM AUTHOR]

Introduction: Erector spinae plane block (ESPB) is a relatively newer approach to the paraspinal fascial plane block. The analgesic efficacy of this block is presently being established in percutaneous nephrolithotomy (PCNL). This meta-analysis was designed to assess the effectiveness of ESPB as a perioperative analgesic technique when compared with conventional analgesia (control) in PCNL. Material and Methods: We performed a systematic review and meta-analysis on the use of ESPB for perioperative analgesia in PCNL for renal stone disease. A systematic literature search was conducted in PubMed, Scopus, ProQuest, and EMBASE using the terms ((erector spinae plane block) AND ((Analgesia) OR (visual analogue scale) OR (VAS) OR (opioid*) OR (morphine) OR (tramadol))) AND ((percutaneous nephrolithotomy) OR (PCNL)) with an intention to include all the randomized studies comparing ESPB with the control group. The risk of bias was assessed using RoB2. Results: A total of 187 records were identified and after the exclusions, a total of 10 trials (560 patients, 503 for primary outcome) were included. Pain scores were significantly lower in the ESPB group as compared to the control group except at the 12th postoperative hour. There were significantly better pain scores at 24 h in the ESPB group as compared to the control group (Standardized mean difference (SMD) −0.46, 95% CI (−1.05, 0.13), moderate GRADE evidence). The total opioid consumption was significantly lower in the ESPB group (SMD −1.50, 95% CI (−1.7 to −1.29, moderate GRADE evidence). Conclusions: ESPB is more effective than conventional analgesia in terms of postoperative opioid consumption after PCNL. Future studies should incorporate better double-blinding techniques, transparent reporting of methods, and sham controls (such as additional dressing post general anesthesia) which were lacking in the current studies. [ABSTRACT FROM AUTHOR]

Awareness among veterinarians has increased regarding the need for comprehensive pain relief, but many companion animal veterinarians do not administer regional analgesia pre-emptively during dental procedures. The middle mental nerve (MMN) block desensitizes the ipsilateral mandibular incisor and canine teeth as well as soft tissues rostral to the delivery site. There is little published information on the efficacy of the MMN block in dogs. The objective of this study was to determine injectate distribution within the mandibular canal using a radiopaque contrast media/methylene blue solution. Half a milliliter of solution was injected within the opening of the middle mental foramen using a standard hypodermic syringe and a 25G x 25 mm needle. The course of the injectate was traced both via computed tomography (CT) and, in some cadavers, gross dissection. Post-treatment CT revealed that in 90% of the cases, the contrast diffused at least as far caudally as the mesial root of the third premolar tooth. The injectate was not identified within the canal of 5% of cadaveric mandibles examined. Although the solution used diffused caudally within the mandibular canal when injected using recommended clinical techniques, this may not completely represent the extent of clinical effects experienced in live patients. This technique also confirmed that the needle does not need to be advanced into the mandibular canal to achieve adequate diffusion to at least the mesial root of the third premolar tooth. [ABSTRACT FROM AUTHOR]

The effects on the stress response, postanesthetic sedation, and altered behavior were evaluated following regional anesthesia and dental treatment in 40 dogs. Serum cortisol and blood glucose concentrations were measured following the administration of levobupivacaine (LBUP) 0.5% and dexmedetomidine (DEX) (0.5 µg/kg) or a placebo. The dogs were randomly assigned to 4 groups of 10 dogs each. All dogs received a regional nerve block using LBUP 0.5%. Group 1 (LBUP + DEX IV) also received DEX intravenously (IV); group 2 (LBUP + PLC IV) also received a placebo IV; group 3 (LBUP + DEX IO) also received DEX in one infraorbital (IO) block; and group 4 (LBUP + DEX IA) also received DEX in one inferior alveolar (IA) block. Serum cortisol and blood glucose concentrations were determined before the administration of oral blocks and at the end of the procedure. Sedation and behavior scores were assessed before premedication and hourly for 6 h after the end of anesthesia. Cortisol concentration did not change in any group at either evaluation time. The glucose concentration was higher (P <.05) only in the LBUP + DEX IA group at the end of the procedure. The sedation score was higher until the end of the observation period only in the LBUP + DEX IV and LBUP + PLC IV groups. No change in behavior score was observed in any of the groups. The reduction of perioperative stress response in all groups was due to the use of LBUP and not DEX. [ABSTRACT FROM AUTHOR]

Dental disease is common in captive-managed macropods, including Bennett's wallabies, and is a significant cause of morbidity and mortality. Dental extractions and debridement of diseased tissue is often necessary for those undergoing treatment for severe dental disease. Regional anesthesia of the dentition is considered standard of care for domestic animals undergoing orofacial surgery, however, it is not routinely performed in macropods due to limited information on dental anatomy and block approaches. Regional block descriptions for the infraorbital, maxillary, inferior alveolar, and mental blocks in domestic dogs and cats were evaluated and adapted for use in Bennett's wallabies based on descriptions of their anatomy and examination of 2 skulls. These approaches were then performed on cadaver heads with iohexol and methylene blue dye, and block placement was assessed on computed tomography scans and by gross dissection. All block approaches described in this study resulted in appropriate placement of regional anesthesia of the dentition in Bennett's wallabies. They can thus be used by clinicians to improve the intra and postoperative pain control of patients and provide a high level of veterinary care. [ABSTRACT FROM AUTHOR]

Maxillary nerve blocks (MNBs) commonly facilitate dental surgeries in standing horses. The goal of this prospective, blinded, cross-over design trial including 15 client-owned horses was to evaluate 3 methods of sensory function testing for confirming a successful MNB. Testing was performed bilaterally before sedation, 5 min after sedation, and 15 and 30 min after MNB with 0.5% bupivacaine and involved a needle prick dorsal to each naris, hemostat clamping of each nostril, and gingival algometry (measuring sensitivity to pain). Responses to stimulation were numerically scored and scores were summed up to a total score. Total score increases on the blocked side by ≥ 2 between baseline and 30 min Post MNB recordings signified a successful MNB. Sedation in the preceding 6 h, presence of sino-nasal disease, side of dental pathology, age, butorphanol administration, and detomidine dosing (µg/kg/min) throughout the tooth extraction procedure were recorded. In 73% of horses, MNB was successful. Sedation in the preceding 6 h (P =.732), age (P =.936), side of pathology (P =.516), and sino-nasal disease (P =.769) were not associated with total scores. Detomidine dosage and butorphanol use did not differ between horses in which the MNB was considered successful and for those in which it was not (P =.967 and P =.538, respectively). Scores obtained with gingival algometry were less closely associated with total scores (rho =.649) than those obtained with needle prick and nostril clamping (rho =.819 and.892, respectively). Therefore, needle prick and nostril clamping are considered the more reliable methods for use in clinical practice to determine the success of an MNB. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate owner assessment of appetite, demeanor, and mouth soreness following dental extractions in dogs receiving either bupivacaine hydrochloride (BH) or liposomal encapsulated bupivacaine (LEB) for dental blocks. Thirty healthy, adult dogs requiring dental extractions were enrolled in the study. All procedures were completed with dogs under general anesthesia. A non-steroidal anti-inflammatory drug was administered subcutaneously in the preoperative period. Dogs were randomly assigned to receive BH or LEB. An owner assessment to evaluate appetite, demeanor, and soreness of mouth was completed at the end of both the first and second day after discharge from the hospital. The total of the owner assessments for day 1 and both days combined was significantly lower for dogs receiving LEB (P =.007). There were no differences in the number of extractions (P =.21), time from block to evaluations (P =.07), in-hospital pain assessments (P =.99), or number of dogs requiring rescue analgesia (P =.99). This study concluded, dogs that received LEB for dental blocks had improved appetite and demeanor, and reduced soreness of mouth, as evaluated by the owner two days postoperatively, when compared to dogs who received BH. [ABSTRACT FROM AUTHOR]

Background: Postoperative pain management is a critical component of perioperative care in pediatric patients. Adequate pain control not only improves patient comfort, but also mitigates adverse physiological responses such as tachycardia, hypertension, immunosuppression, and impaired wound healing. With the growing emphasis on opioid-sparing strategies due to concerns over opioid dependency and misuse, regional analgesia has emerged as a key element of multimodal analgesia protocols. Concerns regarding opioid dependence and misuse have positioned regional analgesia as an essential part of multimodal analgesia, helping to reduce opioid consumption and its associated side effects in pediatric patients. Current Concepts: Regional analgesia includes a range of techniques such as neuraxial, peripheral nerve, and fascial plane blocks. These methods have proven highly effective in reducing postoperative pain and the need for opioids in children. The advent of ultrasound-guided regional anesthesia has greatly improved the safety and accuracy of these techniques. Pediatric-specific anatomical and physiological factors, including immature descending pain modulation pathways and heightened sensitivity to local anesthetics, highlight the importance of customized approaches to regional anesthesia in this demographic. Discussion and Conclusion: Regional analgesia is a cornerstone of multimodal analgesia in pediatric patients, effectively reducing opioid consumption and promoting recovery. Despite challenges such as provider expertise and anatomical considerations, advancements in ultrasound-guided techniques have increased safety and improved precision. Future directions should focus on expanding education and training in pediatric regional anesthesia, as well as conducting high-quality studies to further refine best practices. [ABSTRACT FROM AUTHOR]