Postoperative analgesic efficacy of the thoracoabdominal nerves block through perichondrial approach (TAPA) and modified-TAPA for laparoscopic cholecystectomy: a randomized controlled study

Laparoscopic cholecystectomy is one of the most common surgical procedures. Even though there is less postoperative pain with laparoscopic cholecystectomy than with open cholecystectomy, severe pain can occur, particularly within the first 24 hours. Evaluation of the efficacy of ultrasound-guided interfascial plane blocks for postoperative analgesia of laparoscopic cholecystectomy has recently come to prominence. The aim of our study was to compare the postoperative analgesic efficacy of thoracoabdominal nerves block through perichondrial approach (TAPA) and modified-TAPA (m-TAPA) blocks in patients who underwent laparoscopic cholecystectomy. The present study included 56 patients who underwent laparoscopic cholecystectomy under general anesthesia and received TAPA or m-TAPA block for perioperative analgesia. Each patient signed a written informed consent form. Block times and numerical rating scale (NRS) scores 1, 2, 3, and 12 hours postoperatively, hourly and total tramadol amount of use via the patient-controlled analgesia device, and additional analgesic drug consumption were all recorded. The TAPA group had significantly longer block application times than the m-TAPA group. At 1 and 12 hours, NRS scores were lower in the TAPA group. However, the mean NRS scores, total tramadol use, and use of additional analgesics were comparable between the groups. TAPA and m-TAPA block methods reduced NRS scores by alleviating pain after laparoscopic cholecystectomy procedures, thereby reducing the need for additional analgesics. Block times for TAPA were significantly longer than those for m-TAPA. However, both block applications were completed in a short period, smoothly and safely. The analgesic effect of TAPA block was more distinctive at 1 and 12 hours, and NRS scores were lower. However, we think that both block methods, when used under ultrasound guidance, will provide effective analgesia by supplementing the multimodal analgesia planned for laparoscopic cholecystectomy and other abdominal operations.

Regional scalp block – the key analgesic element of anesthesia for supratentorial craniotomy

This paper presents the key data on the effectiveness and safety of the regional anesthesia of the scalp, also known as the scalp block, for providing perioperative analgesia for supratentorial craniotomy. The authors describe the technique and its limitations and also trace the implementation of the scalp block method into the routine practice of the largest Russian neurosurgical clinic based on personal experience, results of the own research, and analysis of literature data.

Perioperative analgesia for abdominal hysterectomies: a retrospective study

Background. The effectiveness and widespread use of regional anesthesia in combination with a multimodal approach to perioperative analgesia allow them to be used for an increasing number of patients, including those undergoing surgery in gyneco­logy. The purpose of the study was to determine the effectiveness of transversus abdominis plane block as a component of multimodal analgesia compared to no regional methods of analgesia for a total abdominal hysterectomy. Materials and methods. We conducted a retrospective single-center study at the Department of Anaesthesiology and Intensive Care and the Department of Gynecology of Yuriy Semenyuk Rivne Regional Clinical Hospital (Ukraine). The study included patients aged 40–65 years with symptomatic fibroids complicated by vaginal bleedings, who required a total abdominal hysterectomy (supravaginal amputation of the uterus with ovaries). Exclusion criteria were: patient’s refusal to participate in the study at any of its stages, ASA class > IV, body mass index > 40 kg/m2, use of opioid receptor agonists/agonists-antagonists before surgery, uncontrolled arterial hypertension, heart rhythm disorders. Forty-three patients were included in data analysis. Results. It was found that the level of pain on visual analogue scale in the first group reached its maximum values at h12 and h24 stages of the study and was 4.8 [3.3; 5.8] and 5.3 [3.9; 6.4] points, respectively, while in patients of the second group at same stages of the study pain seve-rity was 2.7 [2.3; 3.5] and 2.1 [1.6; 4.1] points (p < 0.05). Significant differences were found in heart rate between the first and the second groups at h24 stage of the study (93 [87; 98] bpm in the first group and 72 [63; 79] bpm in the second, p = 0.05). There were no significant differences in mean blood pressure at all stages of the study; however, there was a tendency towards a decrease in these data throughout the study in the first group of patients. The ave-rage daily dose of nalbuphine at h24 stage has a tendency (p = 0.07) towards a decrease in the second group (40.9 ± 1.1 mg/day) compared with the first group (51.4 ± 2.9 mg/day). At h72 stage, the need in nalbuphine was significantly lower (p < 0.05) in the second group (5.8 ± 0.8 mg/day) compared to the first group (22.5 ± 4.1 mg/day). The average length of hospital stay in the first group was 6.8 ± 0.5 days, in the second one — 4.2 ± 0.2 days (p < 0.05). Conclusions. The use of bilateral transversus abdominis plane block with 0.25% bupivacaine and dexamethasone showed a tendency towards a reduction in the need for nalbuphine in the first postoperative day by 25.7 %, on the third postoperative day — by 3.9 times (p < 0.05). The length of hospital stay in the second group was decreased by 2.6 days compared to the first group (p < 0.05).

Mechanisms of Cancer Inhibition by Local Anesthetics

The use of local anesthetics during surgical treatment of cancer patients is an important part of perioperative analgesia. In recent years, it has been showed that local anesthetics can directly or indirectly affect the progression of tumors. In vitro and in vivo studies have demonstrated that local anesthetics reduced cancer recurrence. The etiology of this effect is likely multifactorial. Numerous mechanisms were proposed based on the local anesthetic used and the type of cancer. Mechanisms center on NaV1.5 channels, Ras homolog gene family member A, cell cycle, endothelial growth factor receptor, calcium Influx, microRNA and mitochondrial, in combination with hyperthermia and transient receptor potential melastatin 7 channels. Local anesthetics significantly decrease the proliferation of cancers, including ovarian, breast, prostate, thyroid, colon, glioma, and histiocytic lymphoma cell cancers, by activating cell death signaling and decreasing survival pathways. We also summarized clinical evidence and randomized trial data to confirm that local anesthetics inhibited tumor progression.

Mechanisms and Efficacy of Intravenous Lipid Emulsion Treatment for Systemic Toxicity From Local Anesthetics

Local anesthetics are widely used clinically for perioperative analgesia to achieve comfort in medical treatment. However, when the concentration of local anesthetics in the blood exceeds the tolerance of the body, local anesthetic systemic toxicity (LAST) will occur. With the development and popularization of positioning technology under direct ultrasound, the risks and cases of LAST associated with direct entry of the anesthetic into the blood vessel have been reduced. Clinical occurrence of LAST usually presents as a series of severe toxic reactions such as myocardial depression, which is life-threatening. In addition to basic life support (airway management, advanced cardiac life support, etc.), intravenous lipid emulsion (ILE) has been introduced as a treatment option in recent years and has gradually become the first-line treatment for LAST. This review introduces the mechanisms of LAST and identifies the clinical symptoms displayed by the central nervous system and cardiovascular system. The paper features the multimodal mechanism of LAST reversal by ILE, describes research progress in the field, and identifies other anesthetics involved in the resuscitation process of LAST. Finally, the review presents key issues in lipid therapy. Although ILE has achieved notable success in the treatment of LAST, adverse reactions and contraindications also exist; therefore, ILE requires a high degree of attention during use. More in-depth research on the treatment mechanism of ILE, the resuscitation dosage and method of ILE, and the combined use with other resuscitation measures is needed to improve the efficacy and safety of clinical resuscitation after LAST in the future.

Perioperative effect of dexmedetomidine on quality of analgesia and hemodynamic parameters in vaginal hysterectomy: A tertiary centre experience

Vaginal hysterectomy Surgery with long acting local anaesthetic like bupivacaine still requires higher doses of analgesics in the post-operative period. Dexmedetomidine is highly selective αadrenoreceptor agonist and sympatholytic drug is a useful adjunct drug in patients undergoing vaginal hysterectomy under continuous spinal epidural block (CSE). We sought to study duration of perioperative analgesia, observe the intra-operative and post-operative hemodynamic changes and post-operative sedation effect of dexmedetomidine.: The study groups were divided as Group D (study group) administered 1 µg/kg Dexmedetomidine and Group C (control group) administered 0.9% saline drip at the rate of 1ml/kg. Dexmedetomidine group had prolonged duration of sensory blockade, duration for 2 dermatomal regression of sensory blockade and the duration for motor block regression to Modified Bromage scale 0. This group had prolonged duration of Time to first request for rescue analgesic.14% patients required mephentermine for management of hypotension.Intraoperative diastolic blood pressure (DBP) was lower in study group while Intraoperative Systolic blood pressure (SBP) was comparable in both the groups. Intravenous dexmedetomidine significantly decreases the heart rate and is associated with higher incidence of bradycardia. It is effective in providing postoperative analgesia and in preventing postoperative shivering with reduced incidence of postoperative nausea and vomiting.

Perioperative analgesia in obese patients

Obesity in general and morbid obesity (MO) in particular are becoming more common around the world. MO is associated with altered physiology of the body and increased number of comorbidities, which can make perioperative pain control particularly difficult in such patients. Given the higher incidence of respiratory disorders, traditional opioid-oriented treatment of pain in patients with MO can often lead to ventilation disorders and increased morbidity and/or mortality. Multimodal analgesia strategies based on a step-by-step, according to the pain severity, opioid-sparing approach can improve patient safety and treatment outcomes. Further progress in understanding the mechanisms of acute pain forces doctors to actively detect and treat both its nociceptive and pro-nociceptive components (hyperalgesia, etc.). Such multimodal analgesia protocols should be standardized and implemented in perioperative care of patients with MO. In addition to standardizing the treatment of postoperative pain, regardless of used regimen of anesthesia and analgesia, some patients with MO require enhanced respiratory monitoring to prevent possible airway side effects. This review briefly describes the physiological changes in obese patients, the pathophysiology of pain, and the evidence-based clinical updates for pain management in MO. Also, the role of opioid-sparing pharmacological adjuvants is discussed and future directions of research in the field of perioperative pain management in patients with MO are highlighted.

Effects of prolonged peri-neural bupivacaine infusion in rat sciatic nerves (axon and myelin)

Background/Objective: Peripheral-nerve blocks (PNBs) using continuous-infusion of local anesthetics are used to provide perioperative analgesia. Yet little research exists to characterize the histopathological effects of continuous long-duration PNBs. Herein we test the hypothesis that continuous peri-neural bupivacaine infusion (3-day vs. 7-day infusion) contributes to histologic injury in a duration-dependent manner using an in vivo model of rat sciatic nerves. Methods: We placed indwelling catheters in 22 rats for infusion with low-dose (0.5mg/kg/hr) bupivacaine or normal saline proximal to the right sciatic nerves for 3 or 7 consecutive days. Hind-limb analgesia was measured using Von-Frey nociceptive testing. At infusion end, rats were sacrificed, bilateral nerves were sectioned and stained with hematoxylin and eosin and CD68 for evaluation of inflammatory response, and eriochrome to assess damage to myelin. Results: Animals receiving continuous infusion of bupivacaine maintained analgesia as demonstrated by significant decrease (50%on average) in nociceptive response in bupivacaine-infused limbs across time points. Both 7-day saline and bupivacaine-infused sciatic nerves showed significantly-increased inflammation by H&E staining compared to untreated native nerve controls (P = 0.0001, P < 0.0001). Extent of inflammation did not vary significantly based on infusate (7-day saline vs. 7-day bupivacaine P > 0.99) or duration (3-day bupivacaine vs 7-day bupivacaine P > 0.99). No significant change in sciatic nerve myelin was found in bupivacaine-infused animals compared to saline-infused controls, regardless of duration. Conclusions: Long-duration (7-day) bupivacaine infusion provided durable post-operative analgesia, yet contributed to equivalent neural inflammation as short duration (3-day) infusion of bupivacaine or saline with no evidence of demyelination.