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Laparoscopic cholecystectomy is a common surgical procedure that frequently results in substantial postoperative pain. Erector spinae plane block (ESPB) has been shown to have beneficial postoperative analgesic effects when used as a part of multimodal analgesia. The aim of this study was to determine whether ESPB improves postoperative recovery quality in patients undergoing laparoscopic cholecystectomy. Evaluation of the effects of ESPB on postoperative pain, opioid consumption, and nausea and vomiting was the secondary objective.In this prospective double-blind study, 82 patients undergoing laparoscopic cholecystectomy were randomised into one of two groups: a standard multimodal analgesic regimen in Group N (control) or an ESPB was performed in Group E. Preoperative and postoperative recovery quality was measured using the 40-item quality of recovery (QoR-40) questionnaire; postoperative pain was evaluated using the numerical rating scale scores.Postoperative mean (standard deviation) QoR-40 scores were higher in Group E (181 [7.3]) than in Group N (167 [11.4]); P0.01. With repeated measures, a significant effect of group and time was demonstrated for the global QoR-40 score, P0.01, indicating better quality of recovery in Group E. Pain scores were significantly lower in Group E than in Group N, both during resting and motion at T1-T8 times (P0.01 at each time). The total amount of tramadol consumed in the first 24 h was lower in Group E [median 0 mg, inter-quartile range (IQR) (0-140)], than in Group N [median 180 mg, IQR (150-240); P0.01].ESPB improved postoperative quality of recovery in patients undergoing laparoscopic cholecystectomy. Moreover, ESPB reduced pain scores and cumulative opioid consumption.NCT04112394.

Background Incomplete peripheral nerve blocks distal to the popliteal region are commonly considered a sciatic and femoral/saphenous nerve block failure. The existence of a much more distal innervation area of the posterior femoral cutaneous nerve (PFCN) as described has not been assumed yet. We therefore investigated the distal termination of the PFCN in the lower leg. Methods In 83 human lower extremities embalmed with Theil's method, the course of the PFCN was investigated from the sub-gluteal fold to the most distal macroscopically dissectible branch. The topographic connection to other landmarks, such as the small saphenous vein or small arteries, was investigated. Results Popliteal ending of the PFCN was found in 9.7% of cases. The PFCN terminated at the proximal or distal lower leg in 45.7% and 44.6% of cases, respectively. The PFCN had a close connection to the Achilles tendon in 13.2% of cases and was found distally to the medial malleolus in one case. The small saphenous vein was close to the PFCN in 90.3% of cases and can therefore be used as a landmark to identify the nerve. In 40.9% of cases, the PFCN was accompanied by a small descending branch of the inferior gluteal artery. In two cases, an innervation of the fibula or calcaneus periosteum was found. Conclusions The PFCN has a much more distal termination in the lower leg than previously demonstrated. To ensure complete anaesthesia of the lower leg and foot, the PFCN must be included in combined peripheral nerve block procedures.

Background Pain after anterior cruciate ligament reconstruction (ACLR) with autologous hamstring graft can be attributed to both arthroscopic surgery and the graft donor site. This study investigated whether donor site pain control was superior with the addition of either peri-hamstring injection or anterior division obturator nerve block in comparison with adductor canal block (ACB) alone. Methods Patients scheduled to undergo knee arthroscopy with ACLR using a graft from the ipsilateral hamstring were randomised to one of three groups. All patients received ACB and multimodal analgesia. Subjects in Group H received peri-hamstring local anaesthetic injection while subjects in Group O received an anterior division of the obturator nerve block, and subjects in Group C served as a control group (ACB alone). Results In 105 subjects undergoing ACLR, there was no significant difference between groups H, O, and C for the primary outcome of pain on movement as assessed by numerical rating scale (NRS) on knee flexion at 2 h after operation (P=0.11). There was no difference in NRS at any time point in the first 48 h after operation, nor was there a difference in oxycodone consumption between the three groups at 24 h (P=0.2). Worst knee pain was initially at the graft donor site in all three groups, which transitioned to anterior knee pain after 12 h. Conclusions The addition of ultrasound-guided peri-hamstring injection or anterior division of obturator nerve block to ACB did not result in a significant reduction in pain or opioid consumption after ACLR with ipsilateral hamstring graft. Clinical trial registration NCT 01868282.

Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's RThe cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's RWe show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed.NCT05018104.

Laparoscopic hepatectomy is associated with trauma and severe pain. We examined whether bilateral, ultrasound-guided, single-injection erector spinae plane block (ESPB) could improve on postoperative analgesia compared with patient-controlled intravenous analgesia in patients undergoing laparoscopic hepatectomy.Fifty adults were randomly allocated to receive patient-controlled intravenous analgesia alone or combined with bilateral single-injection ESPB (ropivacaine 0.5%, 15 ml on each side). Primary outcome was resting pain scores at 3 h postoperatively assessed with visual analogue scale (VAS). Secondary outcomes included VAS scores at rest and during movement at 6, 12, 16, 20, 24, 48, and 72 h postoperatively; use of intraoperative opioids; postoperative rescue analgesia; sleep quality; time of first ambulation; ESPB-related complications; and ropivacaine concentration in plasma.The ESPB group showed lower resting VAS scores at 3 h postoperatively (mean [standard deviation]), 2.0 (0.5) vs 4.3 (0.7), P0.001, and significantly lower scores at rest and during movement at 6-24 h postoperatively. The ESPB group showed lower intraoperative opioid use, lower consumption of rescue analgesia within 72 h postoperatively, and better sleep quality. ESPB subjects began to ambulate 10 h earlier than control subjects. None of the ESPB subjects showed ESPB-related complications, and analysis of a subset of subjects showed that ropivacaine concentrations in plasma decreased gradually over time.Compared with patient-controlled intravenous analgesia only, preoperative ultrasound-guided erector spinae plane block can improve postoperative analgesia, reduce opioid demand, and accelerate recovery in patients undergoing laparoscopic hepatectomy.Chinese Clinical Trial Registry ChiCTR1900020961.

Many regional anaesthetic techniques have been proposed to manage pain after total knee arthroplasty, but the best approach is unclear. We compared opioid consumption in the first 48 h between two different regional anaesthesia strategies in patients undergoing total knee arthroplasty.In this single-centre, prospective study, we randomly allocated 90 patients to a combination of IPACK (interspace between popliteal artery and capsule of the posterior knee), triangle femoral and obturator nerve blocks (distal group), or a combination of sciatic, femoral, obturator, and lateral femoral cutaneous nerve blocks (proximal group). All patients received an opioid-sparing general anaesthesia regimen. The primary outcome was opioid consumption in the first 48 h. Secondary outcomes included opioid consumption in the first 24 h and verbal rating pain scores in the first 48 h.There was no difference in median cumulative oral morphine equivalent consumption at 48 h between the distal and the proximal block groups (33 [18-78] mg vs 30 [22-51] mg, respectively; P=0.29). Median oral morphine equivalent consumption at 24 h was higher in the distal group compared with the proximal group (30 [13-59] vs 15 [0-18], respectively; P0.001). Verbal rating pain scores were lower in the proximal group compared with the distal group on arrival to the postanaesthesia care unit and at 6 and 12 h.In patients undergoing total knee arthroplasty under total intravenous general anaesthesia with a multimodal analgesia regimen, proximal nerve blocks resulted in improved pain scores in the first 12 h and reduced opioid consumption in the first 24 h when compared with distal nerve blocks. No difference in pain scores or opioid consumption was seen at 48 h.NCT04499716.

Background Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. Methods After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. Results Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). Conclusions Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Background Data on UK obstetric anaesthetic practice between 2009 and 2014 were collected by the Obstetric Anaesthetists' Association's National Obstetric Anaesthetic Database. This database provides information on workload, variation in practice, and complication rates. Methods During 2009–14, data were submitted by 190 UK hospitals. The number of hospitals that submitted data each year ranged between 114 and 145. During this 6 yr period, between 27 and 35 data items were requested, although not all hospitals submitted information on all data items. The dataset was assessed for quality and only those data items with acceptable quality were analysed. Results The dataset contains information on 3 030 493 deliveries, 770 545 Caesarean sections, 623 050 women with labour neuraxial analgesia, and 61 121 general anaesthetics for Caesarean section. There was increased use of patient-controlled regimens for labour neuraxial analgesia over the 6 yr period. The mean rate of general anaesthesia used for Caesarean section was 8.75% (95% confidence interval, 8.26–9.24%). The rate of failed intubation for general anaesthesia for Caesarean section was one in 379. Inadvertent dural puncture rates varied between hospitals with a mean of 1.2% (95% confidence interval, 1.02–1.37%). The rate of a high neuraxial block causing unconsciousness was one in 6667 for all blocks. Conclusions This unique large dataset provides a valuable insight of obstetric anaesthetic activity in the UK. Although missing data may place limitations on interpretation, it provides comparative estimates for the rates of rare complications and highlights variations in practice in time and place.

Background Minimally invasive thoracic surgery causes significant postoperative pain. Erector spinae plane (ESP) block and serratus anterior plane (SAP) block promise effective thoracic analgesia compared with systemically administered opioids, but have never been compared in terms of terms of quality of recovery and overall morbidity after minimally invasive thoracic surgery. Methods Sixty adult patients undergoing minimally invasive thoracic surgery were randomly assigned to receive either single-shot ESP or SAP block before surgery using levobupivacaine 0.25%, 30 ml. The primary outcome was quality of patient recovery at 24 h, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included area under the curve (AUC) of pain verbal rating scale (VRS) over time, time to first opioid analgesia, postoperative 24 h opioid consumption, in-hospital comprehensive complication index (CCI) score and hospital stay. Results The QoR-15 score was higher among ESP patients compared with those in the SAP group, mean (standard deviation): 114 (16) vs 102 (22) (P=0.02). Time (min) to first i.v. opioid analgesia in recovery was 32.6 (20.6) in ESP vs 12.7 (9.5) in SAP (P=0.003). AUC at rest was 92 (31) mm h−1 vs 112 (35) in ESP and SAP (P=0.03), respectively, whereas AUC on deep inspiration was 107 mm h−1 (32) vs 129 (32) in ESP and SAP (P=0.01), respectively. VRS pain on movement in ESP and SAP at 24 h was, median (25–75% range): 4 (2–4) vs 5 (3–6) (P=0.04), respectively. Opioid consumption at 24 h postoperatively was 29 (31) vs 39 (34) (P=0.37). Median (25–75%) CCI in ESP and SAP was 1 (0–2) vs 4 (0–26) (P=0.03), whereas hospital stay was 3 (2–6) vs 6 (3–9) days (P=0.17), respectively. Conclusion Compared with SAP, ESP provides superior quality of recovery at 24 h, lower morbidity, and better analgesia after minimally invasive thoracic surgery. Clinical trial registration NCT 03862612.