Pain management during labor: use of intermittent drug delivery devices for improvement of obstetric and neonatal outcome and reduction of healthcare burden: A large non-inferiority randomized clinical trial

Background Automated continuous epidural administration of local anesthetics provides a more stable analgesic block with decreasing of healthcare staff compared to manual boluses administration (TOP-UP) but is associated to high rate of operative vaginal delivery. We hypothesized that the use of programmed intermittent automated boluses (PIEB) is able to provide a good quality of analgesia and decreasing of anesthesiologic workload without increasing the rate of instrumental vaginal birth in comparison with TOP-UP technique. Laboring nulliparous woman aged between 18 and 46 years were randomized to epidural analgesia with 0.0625% levobupivacaine and sufentanil administered by PIEB or by TOP-UP techniques. Primary outcome was instrumental vaginal delivery rate and secondary outcomes were quality of analgesia, total and time-related drugs doses used, motor block, newborn outcome, and anesthesiologic workload. Results Six hundred twenty-nine were randomized, and 628 were included in the intention-to-treat analysis. The rate of instrumental vaginal delivery was similar in the PIEB and TOP-UP groups (13.2% vs 9.7%, OR 1.4 95% CI 0.8 to 2.5; p 0.21). There was no difference between groups regarding mode of delivery (cesarean section vs vaginal birth), newborn outcome, and motor block. Patients in the PIEB group received more total and time-related drugs doses and a better quality of analgesia. Anesthesiological workload was significantly reduced in the PIEB group. Conclusions Our study demonstrated that epidural anesthesia with programmed intermittent epidural boluses by an automated device provides an effective and safe management of labor analgesia with improvement of pain control and sparing of man workload compared to manual top-up protocols.

Comparison of two analgesic block techniques for circumcision: dorsal penile nerve block and caudal block

Background: Circumcision is most common and oldest surgery but also could be frightening for children because of postoperative pain. Authors aim to evaluate postoperative pain conditions of patients by using the visual pain scale (VPS).Methods: Between 2016 and 2018, 168 children undergone circumcision. The patients were splitted into three groups depend on their anesthetic care; the dorsal penile block (DPNB), caudal block (CB) and combine block.Results: The mean age were 95.3±20.9 (65-186) months. There was no significant difference between the CB and combine block in VPS at 1st, 3rd hours and second days (p=0.19, p=0.39 and p=0.9 respectively). The VPS significantly higher in the DPNB arm when compared with caudal and combine block arm at 1st and 3rd hours (p<0.01 and p<0.01 respectively) but there was no significant difference between the DPNB and caudal block at second days (p=0.9). There was no significant difference between groups for analgesic requirements (p=0.07). Incidences of nausea and vomiting were seen rarely especially in the DPNB arm and the difference was not statistically significant among the groups (p=0.9).Conclusions: CB and DPNB are effective techniques for pain relief following penile surgery. CB has superior to DPNB at 1st and 3rd hours but no difference at follow up. Both techniques are appropriate methods for postoperative pain relief.

Combination of pharmacotherapy and lidocaine analgesic block of the peripheral trigeminal branches for trigeminal neuralgia: a pilot study

Classical trigeminal neuralgia (CTN) is treated predominantly by pharmacotherapy but side effects and unsuccessful occurs. The current study was carried out to evaluate the therapeutic effect of combination of pharmacotherapy and lidocaine block. Thirteen patients with CTN managed with pharmacotherapy were recruited and assigned either to no additional treatment (Group I) or to additional analgesic block (Group II). The primary endpoint was the reduction in the frequency of pain episodes in a month assessed at 30 and 90 days. Comparisons of measurements of pain, general health and depression scales were secondary endpoints. The results from the follow-up visits at 30 and 90 days showed the Group II to have larger reduction in the frequency of pain and exhibited a bigger improvement in the scores of the pain, general health and depression scales. The results from this preliminary study suggest a clinical benefit of the combination of pharmacotherapy and lidocaine block.

Neurolytic blockade of the obturator nerve in the treatment of idiopatic obturator neuralgia

Introduction. Idiopathic obturator neuralgia is a rare chronic pain condition. It consists of pain radiating from the obturator nerve territory to the inner thigh. However, the symptomatic obturator neuralgia is commonly caused by the obturator canal bowel hernia that causes painful compressive neuropathy in more than 85% of the cases. Case report. A 61-year-old female who underwent right femoral amputation due to the occlusion of the aortofemoral vascular graft, complained of the pain characterized by its localization in the inguinal region and anterointernal side of the right inner thigh. Computer tomography and MRI findings excluded obturator canal herniation or lumbar plexopathy. A diagnosis of the obturator neuralgia was confirmed by an analgesic block of the obturator nerve. Thereafter, the neurolitic blockade of the right obturator nerve was done. The complete pain relief was achieved. Pain relief was complete in three-month follow-up period. Conclusion. Neurolitic blockade is an efficacious method in treating chronic pain caused by the idiopathic obturator neuralgia.