Anatomical Differences in the Abdominal Wall Between Species with Implications for the Transversus Abdominis Plane Block

With the increased use of simulation based training using animal models for the education of surgical and anaesthetic techniques, an increased understanding of the anatomy of such models and how they compare to humans is required. The transversus abdominis plane block is a regional anaesthetic technique that requires an understanding of the abdominal wall anatomy along with proficient ultrasound use. The current review aims to compare the anatomy of the abdominal wall across species, particularly focussing on the pertinent differences within the class of mammals, and secondarily, it aims to address the implications of these differences for simulation based training of the transversus abdominis plane block. To achieve this, the PubMed, Web of Science and Google Scholar databases were searched for relevant literature. The mammalian abdominal wall differs in its musculature, vasculature or innervation from that of amphibians, birds or reptiles, however, among species of mammals, the structure of the abdominal wall follows a similar framework. Particular differences among mammals include the additional muscular layer of the panniculus carnosus found in most mammals other than humans, the variable arterial origins and dominant vascular supply of the abdominal wall and the number of thoracolumbar nerves innervating the abdominal wall. When using animal models for simulation based training, the pig is recommended for the transversus abdominis plane block given its closely homologous abdominal wall structure, availability and larger comparative size.

Dexamethasone as an Adjuvant to 0.5 % Ropivacaine for Ultrasound Guided Supraclavicular Brachial Plexus Block

BACKGROUND Supraclavicular brachial plexus block is a reliable, regional anaesthetic technique for upper limb surgeries. Also known as “spinal of upper limb”.1 The present study was conducted to assess the analgesic efficacy of dexamethasone as an adjuvant to 0.5 % ropivacaine for ultrasound sonography (USG) guided brachial plexus block. METHODS 50 adult patients of American Society of Anaesthesiologists (ASA) physical status I and II of both genders, aged 18 - 50 years scheduled for elective upper limb surgeries under brachial plexus block via supraclavicular approach were randomised into 2 groups of 25 patients each to receive either 20 ml of 0.5 % ropivacaine with 2 ml of normal saline (group A) or 20 ml of 0.5 % ropivacaine with 2 ml of dexamethasone (8 mg) (group B). RESULTS Use of ultrasound helps in better visualisation of nerves, needle & spread of local anaesthetic at brachial plexus block site. So, less amount of drug volume is required for the block. Time of onset of sensory and motor block was significantly lower in group B compared to group A. Mean duration of motor and sensory block was significantly longer in group B than group A. The duration of postoperative analgesia was 18.79 ± 2.31 hours in group B & 9.06 ± 0.35 hours in group A, with statistically highly significant difference (P < 0.05). There were no perioperative haemodynamic variations between the two groups and no complication of technique or adverse effects due to dexamethasone occurred. CONCLUSIONS Dexamethasone 8 mg has significantly extended duration of analgesia of brachial plexus block with no adverse effects. KEYWORDS Brachial Plexus Block, Ropivacaine, Dexamethasone, Supraclavicular Approach, Ultrasound Guidance

A case report of the successful use of regional anaesthesia and mixed sedative techniques in an adolescent with Duchenne muscular dystrophy

In this case report, we present a 12-year-old male who presented with clubbed feet for Achilles tenotomy with comorbid Duchenne muscular dystrophy and obesity. Owing to his prior surgical history and requirement for a prolonged intensive care unit stay with mechanical ventilation, we opted for a regional anaesthetic technique with mixed pharmacological and non-pharmacological sedation. The patient tolerated the nerve blocks with minimal sedation with midazolam and local anaesthesia and the surgery was performed successfully with light sedation and the help of his favourite song.

Ultrasound to the Rescue: Axillary Clearance under Complete Regional Blockade

No single regional anaesthetic technique is capable of complete anaesthesia of the axillary region. Regional or interfascial nerve blockade could be an effective alternative where administering general anaesthesia is not feasible, with superior analgesia, favourable haemodynamics, and reduced opiate related adverse effects. Ultrasound guidance improves effectiveness and safety profile. We report a case of a successful axillary clearance conducted under combined regional blocks for an axillary nodal recurrence following mastectomy for a breast carcinoma, in a patient who was not fit for general anaesthesia due to a persistent lobar pneumonia and recurrent asthma exacerbations. Our experience and current evidence supersede the initial conceptions of difficult ultrasonic intercostobrachial nerve (ICBN) visualization.

Comparison of Levobupivacaine and Levobupivacaine with Dexmedetomidine for Supraclavicular Brachial Plexus Block in Patients Undergoing Upper Limb Surgeries-A Randomised Controlled Trial

Introduction: Brachial plexus blockade at the supraclavicular level delivers an excellent regional anaesthetic technique with unmatched effectiveness for upper limb surgeries. Levobupivacaine, a safer alternative to the commonly used bupivacaine for regional anaesthesia and addition of α2-agonists like dexmedetomidine further improves the quality of regional anaesthesia. Aim: To evaluate the efficacy of levobupivacaine in combination with dexmedetomidine for supraclavicular brachial plexus block. Materials and Methods: This randomised controlled study enrolled 50 American Society of Anaesthesiologist (ASA) grade I and II patients aged between 18-60 years posted for elective upper limb surgeries. Randomisation was done and the patients were divided into two groups with 25 each, to receive either 39 mL of 0.5% levobupivacaine and 100 μgs (1 mL) of dexmedetomidine in group LD (Levobupivacaine with Dexmedetomidine) and 39 mL of 0.5% levobupivacaine and 1 mL of normal saline in group LS (Levobupivacaine with Saline). The onset and duration of sensory and motor blockade along with duration of analgesia were observed. All Quantitative data were compared and analysed using student’s unpaired t test while qualitative data were analysed using Chi-square test. A p-value of less than 0.05 was considered to be statistically significant. Results: The onset of sensory and motor blockade in group LD was significantly faster when compared to group LS (p<0.001). group LD had a longer mean duration of sensory and motor blockade along with duration of analgesia when compared to group LS (p<0.001). There was a better hemodynamic stability in group LD when compared to group LS. Conclusion: Dexmedetomidine added to levobupivacaine provides significantly shorter onset times, greatly prolongs the duration of sensory and motor blockade along with duration of analgesia without any systemic side effects.

The pericapsular nerve group block: a step towards outpatient total hip arthroplasty?

Introduction: A new regional anaesthetic technique, coined the pericapsular nerve group (PENG) block, targets the anterior hip capsule by blocking the articular branches of the femoral nerve and accessory obturator nerve. In this study, we evaluated: (1) patient outcomes; (2) postoperative pain scores; and (3) postoperative opioid consumption in total hip arthroplasty (THA) patients who received a PENG block in comparison to a control group. Methods: A retrospective chart review was performed for patients who underwent primary THA and met criteria at a single institution ( n = 48), with an additional cohort of patients collected as controls ( n = 48). Postoperative pain scores were measured by obtaining the cumulative visual analogue scores (VAS) at 12-hour intervals until the 48-hour benchmark. All administered opioids were collected from postoperative day (POD) 0 to POD2 and converted to morphine milligram equivalents (MME). Results: In the PENG group, length of stay was significantly shorter ( p < 0.001) and the initial postoperative distance walked was significantly farther ( p = 0.001). The PENG group consistently demonstrated significantly lower mean cumulative pain scores until the 48-hour mark ( p < 0.001 for all). Patients receiving the PENG block also experienced a significantly longer therapeutic window before requiring their first opioid ( p < 0.002). The PENG group required significantly less opioid MMEs on POD1, POD2, and cumulatively over the entire stay ( p < 0.022 for all). Conclusions: Our findings suggest that the PENG block has the potential of impacting THA recovery pathways and contributing to cost savings. Thus, its use further supports the transition to the outpatient setting and drives us towards achieving value-driven healthcare.

A comparative study of postoperative analgesic efficacy between TAP block with wound infiltration in open gynaecological surgeries

Background: Gynaecological surgeries are performed by abdominal incision is common and post-operative pain and discomfort is always anticipated. TAP block is a regional anaesthetic technique which blocks the abdominal neural afferents by administrating local anaesthetic drugs into the neuro-fascial plane. The other method for postoperative analgesia is surgical wound infiltration with local anaesthetic drugs. The aim of this study was to evaluate the post-operative analgesic efficacy of TAP block versus wound infiltration in gynaecological surgeries.Methods: The study was a prospective randomized study conducted on patients undergoing open gynaecological surgeries, conducted at the Government medical college and ESI hospital, Coimbatore. The study was initiated after obtaining an ethical clearance from the institution. Group A: patients who underwent bilateral TAP block with 0.3 ml/kg 0.25% Bupivacaine on each side. Group B: patients who received wound infiltration of 0.25% Bupivacaine 0.6ml/kg.Results: TAP block provided superior analgesic effect than the surgical site infiltration group, without significant changes in the hemodynamic parameters. The duration of analgesia was longer and the need of Tramadol in the postoperative period was found to be lesser in the TAP block group as compared to wound infiltration group.Conclusions: The TAP block is an effective and safe technique for postoperative analgesia for gynaecological surgeries than compared to the surgical wound infiltration. The requirement of Tramadol as a postoperative analgesia was less with TAP block compared to surgical wound infiltration.

Effect of adding various doses of clonidine as an adjunct in Transversus abdominis plane block in unilateral inguinal hernioplasty

Background: Transverses abdominis plane (TAP) block is a new regional anaesthetic technique for postoperative analgesia in abdominal surgeries, as a part of multimodal analgesia. We evaluated effect of two different doses of clonidine as an adjunct in TAP block in patients underwent unilateral inguinal hernioplasty.Methods: Sixty adult patients undergoing unilateral inguinal hernioplasty were randomized into two groups, Group A (n=30) received bilateral TAP block with bupivacaine 0.25% 38cc + clonidine (1cc) 150 microgram +1cc NS=40cc, Group B (n=30) received bupivacaine 0.25% 38cc+clonidine (2cc) 300 microgram=40cc, at the end of surgery. The postoperative pain was evaluated by visual analog score (VAS) for pain scoring at 2, 4, 6, 12 and at 24 hours. Subjective assessment of duration of analgesia was done.Results: The VAS score in patients who received clonidine 300 microgram Group B as an adjunct was significantly lower than who received 150 microgram Group A. Duration of analgesia was longer in Group B. 2 patients in Group B showed bradycardia treated with atropine. Sedation score was lesser in Group A.Conclusions: Clonidine showed dose dependant analgesia and adverse effect in TAP block for postoperative analgesia. Higher doses of clonidine may be used as an adjunct in TAP block.