Transmuscular Quadratus Lumborum Block for Postoperative Analgesia in Laparoscopic Colorectal Surgery

Background: Transmuscular Quadratus Lumborum Block (TQLB) is a newer modality for postoperative pain management. But, its efficacy after laparoscopic colorectal surgery is little researched. The aim of our trial was to access the analgesic efficacy of TQLB in colorectal surgery.Methods:This study was done in 64 patients posted for colorectal surgery who were divided into two groups of 32 each. TQLB was given bilaterally in group RQ with 20 ml of 0.375% ropivacaine and in group SQ with 20 ml saline. Patients were operated under general anesthesia and were examined for pain at different time points postoperatively. Time required for first analgesic demand was our primary endpoint. Secondary endpoints were total rescue analgesia (paracetamol) required in 24 hrs, pain scores, nausea, vomiting, sedation and any other complications.Results:The time required for first analgesic demand was 3.9± 0.8hrs in RQ group and 0.1± 0.2 hrs in group SQ which was statistically significant. The total paracetamol consumption in 24 hours was1.2± 0.4 gm in group RQ and 2.9± 0.7gm in group SQ ,the difference being remarkable.Conclusion:Transmuscular quadratus lumborum block can produce quality analgesia after laparoscopic colorectal surgery. TQLB not only improves the visual analogue scale (VAS) score but also decreases the rescue analgesic consumption without any complications.

A Comparison of effect of preemptive versus postoperative use of ultrasound-guided bilateral transversus abdominis plane (TAP) block on pain relief after laparoscopic cholecystectomy

Nowadays, there are various methods to manage pain after laparoscopic cholecystectomy. The aim of this study was to compare the effectof preemptive versus postoperative use of ultrasound-guided transversus abdominis plane (USG-TAP) block on pain relief after laparoscopic cholecystectomy. In this single-blinded randomized clinical trial, the patients who were candidates for laparoscopic cholecystectomy were randomly divided into the two groups (n = 38 per group). In the preemptive group (PG) after the induction of anesthesia and in the postoperative group (POG) after the end of surgery and before the extubation, bilateral ultrasound-guided transversus abdominis plane (TAP) block was performed on patients using 20 cc of ropivacaine 0.25%. Both groups received patient controlled IV analgesia (PCIA) containing Acetaminophen (20 mg/ml) plus ketorolac (0.6 mg/ml) as a standard postoperative analgesia and meperidine 20 mg q 4 h PRN for rescue analgesia. Using the numerical rating scales (NSR), the patients’ pain intensity was assessed at time of arrival to the PACU and in 2th, 4th, 8th, 12th, 24th h. Primary outcome of interest is NSR at rest and coughing in the PACU and in 2th, 4th, 8th, 12th, 24th h. Secondary outcomes of interests were the time to first post-surgical rescue analgesic and level of patients’ pain control satisfaction in the first 24 h. The USG-TAP block significantly decreased pain score in the POG compared to the PG, and also the pain was relieved at rest especially in 8 and 12 h (p value ≤ 0.05) after the surgery. Pain score after coughing during recovery at 2, 8 and 12 h after the operation were significantly decreased. (p value ≤ 0.05) The patient satisfaction scores in the POG were significantly higher in all times. There was a statistically significant difference between the two groups in terms of rate of postoperative nausea and vomiting (PONV), indicating that patients in the POG had significantly lower incidences of the PONV compared tothe PG. The time to first analgesic request was significantly shorterin the POG, which was statistically significant (p value = 0.089). There was no statistically significant difference between the two groups in terms of consumption of analgesics. The postoperative TAP block could offer better postoperative analgesia than preepmtive TAP block.

Intravenous Dexmedetomidine as an Adjunct to Neuraxial Anesthesia in Cesarean Delivery: A Retrospective Chart Review

Background. Dexmedetomidine is a selective α-2 agonist commonly used for sedation that has been used in obstetric anesthesia for multimodal labor analgesia, postcesarean delivery analgesia, and perioperative shivering. This study evaluated the role of intravenous dexmedetomidine to provide rescue analgesia and/or sedation during cesarean delivery under neuraxial anesthesia. Methods. We conducted a single-center, retrospective cohort study of all parturients undergoing cesarean delivery under neuraxial anesthesia between December 1, 2018, and November 30, 2019, who required supplemental analgesia during the procedure. Patients were divided into two groups: patients who received intravenous dexmedetomidine (Dexmed group) and patients who received adjunct medications such as fentanyl, midazolam, ketamine, and nitrous oxide (Standard group). Primary outcome was incidence of conversion to general anesthesia. Results. During the study period, 107 patients received adjunct medications. There was no difference in conversion to general anesthesia between the Dexmed group and the Standard group (6% (4/62) vs. 9% (4/45); p = 0.718 ). In the Dexmed group, the mean dexmedetomidine dose received was 37 μg (range 10 to 140 μg). While the use of inotropic/vasopressor medications was common and similar in both groups, there was an increase in the incidence of bradycardia (Dexmed 15% vs. Standard 2%; p = 0.042 ) but not hypotension (Dexmed 24% vs. Standard 24%; p = 1.00 ) in the Dexmed group. Conclusion. In patients who required supplemental analgesia for cesarean delivery, those who received dexmedetomidine versus other medications had a similar rate of conversion to general anesthesia, a statistically significant increase in bradycardia, but no difference in the incidence of hypotension.

Intravenous Acetaminophen Does Not Provide Adequate Postoperative Analgesia in Dogs Following Ovariohysterectomy

(1) Objective: To investigate the analgesic effects of intravenous acetaminophen after intravenous administration in dogs presenting for ovariohysterectomy. (2) Methods: 14 ASA I client-owned female entire dogs. In this randomized, blinded, clinical study, dogs were given meperidine and acepromazine intramuscularly before induction of anesthesia with intravenous propofol. Anesthesia was maintained with isoflurane in oxygen. Intravenous acetaminophen 20 mg/kg or 0.9% NaCl was administered postoperatively. Pain assessments were conducted using the Glasgow Pain Scale short form before premedication and at 10, 20, 60, 120, and 180 min post-extubation or until rescue analgesia was given. The pain scores, times, and incidences of rescue analgesia between the groups was compared. Blood was collected before and 2, 5, 10, 20, 40, and 80 min after acetaminophen administration. Acetaminophen plasma concentration was quantified by liquid chromatography-mass spectrometry. The acetaminophen plasma concentration at the time of each pain score evaluation was subsequently calculated. (3) Results: There was no significant difference in pain scores at 10 min, highest pain scores, or time of rescue analgesia between groups. In each group, 3 dogs (43%) received rescue analgesia within 20 min. (4) Conclusions: Following ovariohysterectomy in dogs, there was no detectable analgesic effect of a 20 mg/kg dosage of intravenous acetaminophen administered at the end of surgery.

Pain Management in Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Background: Pain management is an important priority in the treatment of acute pancreatitis (AP). Current evidence and guideline recommendations are inconsistent on the most effective analgesic protocol. This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the safety and efficacy of analgesics for pain relief in AP.Methods: A literature search was performed to identify all RCTs assessing analgesics in patients with AP. The primary outcome was the number of participants who needed rescue analgesia. Study quality was assessed using Jadad score. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CI) were analysed using a random-effects model.Results: Twelve studies comprising 699 patients with AP (83% mild AP) were analysed. The tested analgesics significantly decreased the need for rescue analgesia (3 studies, OR.36, 95% CI 0.21 to 0.60) vs. placebo or conventional treatment. The analgesics also improved the pain score [Visual Analogue Scale (Δ-VAS)] at 24 h (WMD 18.46, 0.84 to 36.07) and by the 3rd to 7th days (WMD 11.57, 0.87 to 22.28). Opioids vs. non-opioids were associated with a decrease in the need for rescue analgesia (6 studies, OR 0.25, 95% CI 0.07 to 0.86, p = 0.03) but without significance in pain score. In subgroup analyses, opioids were similar to non-steroidal anti-inflammatory drugs (NSAIDs) regarding the primary outcome (4 studies, OR 0.56, 95% CI 0.24 to 1.32, p = 0.18). There were no significant differences in other clinical outcomes and rate of adverse events. Other studies, comparing epidural anaesthesia vs. patient-controlled analgesia and opioid (buprenorphine) vs. opioid (pethidine) did not show significant difference in primary outcome. Study quality issues significantly contributed to overall study heterogeneity.Conclusions: NSAIDs and opioids are equally effective in decreasing the need for rescue analgesia in patients with mild AP. The relative paucity of trials and high-quality data in this setting is notable and the optimal analgesic strategy for patients with moderately severe and severe AP still requires to be determined.

A COMPARISON OF POST-OPERATIVE ANALGESIA WITH INTRAOPERATIVE PECTORAL NERVE BLOCK VERSUS CONVENTIONAL TECHNIQUE IN PATIENTS UNDERGOING MODIFIED RADICAL MASTECTOMY: A PROSPECTIVE, RANDOMIZED, AND DOUBLE-BLINDED STUDY

Objective: We administered intraoperative pectoral nerve block after tissue resection was over and assessed its analgesic efficacy with conventional post-operative intravenous opioids in patients undergoing modified radical mastectomy. Methods: Sixty patients undergoing modified radical mastectomy surgery were enrolled in this prospective, randomized, and doubleblinded study. After general anesthesia and surgical resection in both groups, Group P received pectoralis (PECS) block under vision with ropivacaine at two points: 20 ml in the fascia over serratus anterior and 10 ml in the fascia between pectoral major and minor at the level of the third rib and Group T received tramadol (75 mg) in thrice daily frequency and 2% lignocaine infiltration at suture site. Primary objectives were to assess visual analog scale (VAS) scores over 24 h, time to first request for rescue analgesia (ketorolac) and total dose of analgesics needed, and secondary outcome was adverse effects and patient satisfaction score. “Mann–Whitney U test” and “Chi-square/Fischer exact test” were used for quantitative and categorical variables, respectively. Results: The mean time to the first rescue analgesia was 1175±120.21 and 1175±77.35 min and total analgesia requirement was equal (30.00±0.00 mg) in Group P and Group T, respectively. The mean VAS score over 24 h was comparable in both the groups. PECS block group had significantly less adverse effects and better satisfaction score. Conclusion: PECS block has similar analgesic efficacy as opioids but with better ability to mobilize the respective arm, better patient satisfaction score, and lesser adverse effects.

Laparoscopic-Guided Ropivacaine Trocar-Site Infiltration Can Improve Post-Operative Pain Control after Laparoscopic Adrenalectomy

Background There is no consensus on pain control in patients undergoing laparoscopy; nowadays, conventional therapy may be improved by transversus abdominis plane block. The aim of this evaluation is to investigate the role of laparoscopic-assisted trocar-site ropivacaine infiltration during adrenalectomy in pain control Methods This is a retrospective evaluation of a prospectively maintained database including patients undergoing adrenalectomy. Patients were divided into 2 groups: Group A patients received laparoscopic-assisted trocar-site infiltration of 7.5 mg/mL ropivacaine and Group B patients did not receive any infiltration. All patients received a 24-hour infusion of 20 mg morphine; pain was checked at 6, 24, and 48 hours after surgery by Visual Analogue Scale (VAS) score. A rescue analgesia by was given if VAS score was > 4 or on patient request. Results No differences in operative time, complications, and post-operative stay and no complications related to trocar-site infiltration were found. 6-hour and 48-hour VAS scores were not found to be significantly different between groups, even if a slight decrease in VAS score in Group A was reported. Group A showed significant reduction in VAS score at 24 hours (2.44 +/− .41 vs 3.01 +/− .78, P < .005) and in the number of patients requiring further analgesic drugs administration (40.6% vs 57.8%, P < .005) Conclusions Laparoscopic-guided trocar-site ropivacaine infiltration can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic adrenalectomy. The retrospective nature of the study and the lack of a consistent series of patients require further evaluations.

A Comparative Study between Analgesic Efficacy of Intrathecal Buprenorphine and USG-Guided Transversus Abdominis Plane Block in Patients Undergoing Cesarean Section under Spinal Anesthesia

Objective The aim of this study was to evaluate and compare the postoperative analgesic efficacy of intrathecal buprenorphine with ultrasonography (USG)-guided transversus abdominis plane (TAP) block in patients of cesarean section. Materials and Methods: Sixty American Society of Anesthesiologists grade I and II pregnant women aged between 20 and 40 years requiring lower segment cesarean section were included in this study. Study Design A prospective randomized comparative study. Study Groups Group A received intrathecal hyperbaric bupivacaine 0.5% 1.8 mL with 60 µg buprenorphine. Group B received intrathecal hyperbaric bupivacaine 0.5% 1.8 mL with 0.2 mL sterile normal saline and at the end of surgery USG-guided bilateral TAP block was given with 20 mL 0.25% bupivacaine on each side of abdomen. Results The mean ± standard deviation of time to first rescue analgesia in Group A and group B was 9.17 ± 0.64 hours and 5.59 ± 0.50 hours, respectively. Distribution of mean time to first rescue analgesia among the cases studied is significantly higher in group A compared with group B. The distribution of paracetamol and tramadol requirement in first 24 hours among the cases studied was significantly higher in group B compared with group A. Conclusion The addition of buprenorphine to intrathecal hyperbaric bupivacaine has advantages over USG-guided TAP block for postoperative analgesia after cesarean section—longer duration of postoperative analgesia, lower analgesic requirements over first 24 hours, and cost–effectiveness.

Evaluation of Quadratus Lumborum Block as Part of an Opioid-Free Anaesthesia for Canine Ovariohysterectomy

Quadratus lumborum block (QLB) is used to provide analgesia for abdominal surgery in humans. The aim of this study was to assess an anaesthetic protocol involving the QLB for canine ovariohysterectomy. Ten dogs were included. Anaesthetic protocol consisted of premedication with IM medetomidine (20 μg kg−1) and SC meloxicam (0.1 mg kg−1), induction with propofol to effect, and maintenance with sevoflurane in oxygen/medical air. QLB was performed injecting 0.4 mL kg−1 of 0.25% bupivacaine/iohexol per side. Computed Tomography (CT) was performed before and after surgery. Fentanyl was administered as rescue analgesia during surgery. The Short Form of The Glasgow Composite Pain Scale and thermal threshold (TT) at the level of the elbow, T10, T13 and L3 were assessed before premedication and every hour postoperatively. Methadone was given as rescue analgesia postoperatively when pain score was >3. A Yuen’s test on trimmed means for dependent samples was used to analyse the data (p < 0.05). CT images showed spreading of the contrast/block for a median (range) of 3 (2–5) vertebrae, without differences between preoperative and postoperative images. One dog needed rescue analgesia during surgery. Pain score was less than 4/24 in all the animals during the first 4 h after surgery. TT showed a significant increased signal in all the areas tested, apart from the humerus, 30 min after surgery. The QLB may provide additional analgesia for canine ovariohysterectomy. Further studies are needed to assess the specific contribution of the QLB in abdominal analgesia.