Search

To describe an ultrasound-guided suprazygomatic approach to the trigeminal nerve block in cat cadavers. Prospective descriptive study. Ten feline cadaver heads. A 25:75 methylene blue–iopamidol mixture (0.1 mL cm–1 cranium length) was injected into 10 cadaver heads using an ultrasound-guided suprazygomatic approach. A computed tomography (CT) scan was performed to identify contrast presence at the orbital fissure, foramen rotundum and ovale, followed by anatomical dissection to identify staining of the pterygopalatine fossa (PPF), extraconal retrobulbar area, mandibular and maxillary nerves. Descriptive statistics were used to summarize results. A total of 20 injections were performed. Of these, 1/20 misinjection occurred and excluded from further reporting. The volume of injectate was 0.9 (0.9–1.1) mL [median (range)]. Staining of the PPF, extraconal space, maxillary and mandibular nerves over more than 6 mm was achieved in 19/19 (100%), 18/19 (95%), 17/19 (89%) and 19/19 (100%) of injections, respectively. CT showed presence of contrast within 5 mm of the orbital fissure, foramen rotundum and ovale in 18/19 (95%), 19/19 (100%) and 19/19 (100%) of the injections, respectively. No intracranial migration was observed. This cadaver study illustrates that the suprazygomatic ultrasound-guided trigeminal nerve injection technique can successfully stain the PPF, retrobulbar cone extraconally, mandibular and maxillary nerves. Consequently, this technique has the potential to be used in vivo in cats to desensitize areas innervated by the trigeminal nerve. [ABSTRACT FROM AUTHOR]

Chronic postsurgical pain (CPSP) significantly impairs quality of life and poses a substantial healthcare burden, affecting up to a quarter of patients undergoing surgery. Although acute pain is recognised as a predictor for CPSP development, the role of patient experience remains underexplored. This study examines the predictive value of patient experience alongside traditional risk factors for CPSP after orthopaedic surgery. An exploratory analysis was conducted on 294 patients from a multicentre randomised clinical trial comparing continuous perineural analgesia and single-injection nerve block in ambulatory orthopaedic surgeries. Patient experience was assessed using the Evaluation du Vecu de l'Anesthésie Générale (EVAN-G) validated questionnaire. Factors associated with CPSP at 90 days after surgery were identified through univariate and multivariate analyses, incorporating patient-reported outcomes and classical variables. Out of 219 patients with complete data, 63 (29%) developed CPSP at day 90. Multivariate analysis revealed a poor pain experience, as assessed by the pain dimension of EVAN-G on postoperative day 2, as an independent predictor of CPSP (odds ratio 6.45, 95% confidence interval 1.65–25.26, P <0.01). Poor pain experience was associated with an augmented risk of CPSP. This study underscores the role of patient-reported outcomes, specifically the pain experience dimension captured by the EVAN-G scale, in prediction of CPSP 90 days after surgery. It suggests a shift from conventional assessments of pain intensity to a comprehensive understanding of pain experience, advocating for tailored pain management approaches that could reduce chronic pain, thereby improving patient quality of life and functional recovery. [ABSTRACT FROM AUTHOR]

Neuropathy of the lateral cutaneous branch of the iliohypogastric nerve (LCBIN) may represent a differential diagnosis for greater trochanteric pain syndrome (GTPS). Ultrasound-guided neural blockade of the LCBIN may lead to diagnosis of this neuropathy. The aim of this study was to evaluate the accuracy of ultrasound-guided nerve block in cadavers and to present a first clinical case series of patients with neuropathy of the LCBIN where the workup for GTPS remained unremarkable. Ultrasound-guided nerve block led to pain relief in these patients, indicating LCBIN neuropathy. First, ultrasound-guided injections at the LCBIN were performed bilaterally in 24 fresh, non-frozen, non-embalmed body donors. Accuracy and nerve localization were validated by anatomic dissection. Second, a clinical case series of nine patients with suspected GTPS who underwent ultrasound-guided diagnostic LCBIN blockade was retrospectively analyzed. Ultrasound-guided injections at the LCBIN yielded 91.7% accuracy (95% confidence interval: 0.80–0.98). On the right side the nerve was found within a range of 3–14 cm from the anterior superior iliac spine, and within a range of 7–15 cm on the left side. This clinical case series indicates that ultrasound-guided blockade at the LCBIN provides temporary pain relief and indicates the presence of LCBIN neuropathy. Ultrasound has demonstrated high accuracy for localization and injection guidance in the examination of LCBIN. Ultrasound-guided injection of local anesthetics may help to identify LCBIN neuropathy as a differential diagnosis in patients with suspected GTPS. [ABSTRACT FROM AUTHOR]

Ni Eochagain and colleagues report that programmed intermittent bolus and continuous infusion regimens in continuous erector spinae plane (ESP) block catheters produced similar quality of recovery (QoR-15) scores, pain scores, and use of rescue opioids after video-assisted thoracic surgery. This is a reassuring finding for practitioners without access to pumps with programmed intermittent bolus functionality. Nevertheless, it remains plausible that the benefit of one regimen over another might vary depending on the specific infusion parameters. There continues to be scope for research into optimising programmed intermittent bolus delivery and dosing regimens and identifying the most appropriate clinical applications for this mode of infusion. [ABSTRACT FROM AUTHOR]

Regional anaesthesia techniques, including the erector spinae fascial plane (ESP) block, reduce postoperative pain after video-assisted thoracoscopic surgery (VATS). Fascial plane blocks rely on spread of local anaesthetic between muscle layers, and thus, intermittent boluses might increase their clinical effectiveness. We tested the hypothesis that postoperative ESP analgesia with a programmed intermittent bolus (PIB) regimen is better than a continuous infusion (CI) regimen in terms of quality of recovery after VATS. We undertook a prospective, double-blinded, randomised, controlled trial involving 60 patients undergoing VATS. All participants received ESP block catheters and were randomly assigned to CI or PIB of local anaesthetic regimen for postoperative analgesia. The primary outcome was Quality of Recovery-15 (QoR-15) score 24 h after surgery. Secondary outcomes included postoperative respiratory function, opioid consumption, verbal rating pain score, time to first mobilisation, nausea, vomiting, and length of hospital stay. Overall QoR-15 scores at 24 h after VATS were similar (PIB 115.5 [interquartile range 107–125] vs CI 110 [93–128]; Δ<6, P =0.29). The only quality of recovery descriptor showing a significant difference was nausea and vomiting, which was favourable in the PIB group (10 [10–10] vs 10 [7–10]; P =0.03). Requirement for rescue antiemetics up to 24 h after surgery was lower in the PIB group (4 [14%] vs 11 [41%]; P =0.04). There were no differences in other secondary outcomes between groups. Delivering ESP block analgesia after VATS via a PIB regimen resulted in similar QoR-15 at 24 h compared with a CI regimen. [ABSTRACT FROM AUTHOR]

Exploration of early practicing dental professionals' awareness and attitude toward inferior alveolar nerve block IANB will directly inform efforts to improve clinical practices and ensure patient safety. The aim was to highlight the students, interns, and junior dentists' awareness and attitude toward the IANB, failure, and related complications in the Kingdom of Saudi Arabia (KSA). An open web-based survey prepared according to the Checklist for reporting results of Internet e-surveys CHERRIES recommendations was designed and carried out across different regions of the KSA. The questionnaire was composed of four main sections including the participant's details, and qualifications; inferior alveolar nerve block delivery; participants' education, and training-related questions; and attitudes toward proposed solutions to overcome the related failure and complications. 262 participants completed the questionnaire (94 dental students, 79 interns, and 89 junior dentists). There was a significant difference in the following findings: males performed IANBs more frequently than females (P < 0.05); females, students, and private practice/University type showed less attendance to workshops and seminars on IANB with more need for training (P < 0.05); females were more in agreement with "continuous education courses" and "workshops done by specialists" to propose solutions to overcome IANB failure (P < 0.05). The multivariate logistic regression analysis showed that qualification and attendance of a training course were strong predictors of participants' readiness to manage IANB complications (P < 0.05). The findings emphasize how crucial it is for early dental practitioners to participate in continuing professional development programs to enhance their capacity to administer IANB and handle complications. [ABSTRACT FROM AUTHOR]

In patients who are candidates for craniotomy, scalp nerve blocks have been shown to be effective in relieving pain intensity as well as postoperative hemodynamic stability after surgery, but the results have been inconsistent. We aimed to assess the effect of scalp block on pain control, intraoperative drug use under Analgesia Nociception Index (ANI) monitoring, and postoperative pain in patients who were candidates for elective craniotomy. In this randomized, single-blinded clinical trial study, candidates for craniotomy were randomly (using the block randomization method) divided into 2 groups before entering the operating room. The first group received a scalp block with bupivacaine (intervention), and the second group did not receive a scalp block (control) besides the routine anesthetic procedure in these patients. ANI, hemodynamic parameters, and the amounts of received remifentanil were conducted and compared. Patients under scalp block received less dosage of fentanyl than the nonscalp block group (mean = 57.14 ± 15.59 mcg vs. 250.00 ± 65.04 mcg, respectively). Similarly, the dose of remifentanil required in the scalp block group was less (mean = 3.04 ± 1.95 mg and 5.54 ± 2.57 mg, respectively). No difference was observed in hemodynamic parameters such as blood pressure and heart rate (before, during, and after surgery). However, the group receiving scalp block had higher ANI means than the control group. Scalp nerve block has an effective role in pain control (increasing ANI), consequently reducing the need for analgesic drugs such as fentanyl and remifentanil following craniotomy without changing the hemodynamic condition. [ABSTRACT FROM AUTHOR]

The present study evaluated the effect of 2 different back pressure-based supplemental anesthesia on postoperative pain in patients receiving endodontic treatment for a mandibular molar with symptomatic irreversible pulpitis. One-hundred-thirty-five adult patients with symptomatic irreversible pulpits in a mandibular first or second molar, received an initial inferior alveolar nerve block (IANB) injection with 2% lidocaine with 1:80,000 epinephrine. Ten minutes following the injection, access to cavity preparation began. Lip numbness was a must for all patients. The Heft-Parker visual analogue scale (HP-VAS) was used to measure pain during endodontic therapy. Success of primary injections was defined as no or mild pain (less than 55 mm on HP-VAS) during access preparation. The patients with initial successful anesthesia served as control and received endodontic treatment. Ninety-five patients with unsuccessful primary anesthesia randomly received either intraligamentary injections of 2% lidocaine with 1:80,000 epinephrine or intrapulpal injections with similar anesthetic solution. Endodontic treatment was re-initiated and canals were instrumented till working length under copious irrigation. Intracanal medicament of calcium hydroxide was placed and teeth received a temporary restoration. Postoperative pain was measured at 2 hours, 4 hours, 6 hours, 24 hours, and 3 days. Data were analyzed using the Pearson chi-square test, one-way analysis of variance, and one-way repeated measures analysis of variance. The initial initial inferior alveolar nerve block was successful in 40 cases (out of 135). The intraligamentary injections were successful in 33 out of 47 cases (70%), and intrapulpal injections were successful in all cases (45/45). The patients receiving intraligamentary injections reported significantly higher pain scores at all intervals till 24 hours. After 3 days, the pain significantly reduced in all the groups with no significant difference between them. Patients receiving supplementary intraligamentary injections can experience increased postoperative pain till 24 hours after the endodontic treatment. The pain scores reduced to the level of the control group after 3 days. [ABSTRACT FROM AUTHOR]

Peripheral nerve blocks may be essential elements in a multimodal pain management regime following foot and ankle surgery. We assessed the effects of ankle blocks compared with no intervention/sham block or a sciatic nerve block in patients undergoing surgery of the foot or ankle. We searched CENTRAL, Medline, and Embase for randomised clinical trials comparing ankle block with no intervention/sham block or a sciatic nerve block for patients undergoing surgery of the foot or ankle. Our primary outcomes were duration of analgesia and cumulative 24-hour opioid consumption. We followed the recommendations of the Cochrane Handbook, and performed meta-analysis, Trial Sequential Analysis (TSA), and assessed the risk of bias and certainty of the evidence using the GRADE approach. We included five trials (362 participants) comparing ankle block with no intervention/sham block and three trials (247 participants) comparing ankle block with a sciatic nerve block. Ankle block may increase the duration of analgesia when compared with no intervention/sham block (MD 431 min; 96.7% CI 208 to 654), but the evidence was very uncertain. Duration was decreased when compared with a sciatic nerve block (MD −410 min; 96.7% CI −462 to −358). The ankle block duration was probably important in both comparisons. The effects on cumulative 24-hour opioid consumption were very uncertain in both comparisons. Ankle block may increase the duration of analgesia when compared with no intervention/sham block, but the evidence was very uncertain, and decrease the duration of analgesia when compared with a sciatic nerve block. The ankle block duration was probably clinically important in both comparisons. The effects on cumulative 24-hour opioid consumption were very uncertain. [ABSTRACT FROM AUTHOR]

There is an urgent clinical need to develop nerve-blocking agents capable of inducing long duration sensory block without muscle weakness or paralysis to treat post-operative and chronic pain conditions. Here, we report a galacturonic acid-capsaicin (GalA-CAP) prodrug as an effective nociceptive-selective axon blocking agent. Capsaicin selectively acts on nociceptive signaling without motor nerve blockade or disruption of proprioception and touch sensation, and the galacturonic acid moiety enhance prodrug permeability across the restrictive peripheral nerve barriers (PNBs) via carrier-mediated transport by the facilitative glucose transporters (GLUTs). In addition, following prodrug transport across PNBs, the inactive prodrug is converted to active capsaicin through linker hydrolysis, leading to sustained drug release. A single injection of GalA-CAP prodrug at the sciatic nerves of rats led to nociceptive-selective nerve blockade lasting for 234 ± 37 h, which is a sufficient duration to address the most intense period of postsurgical pain. Furthermore, the prodrug markedly mitigated capsaicin-associated side effects, leading to a notable decrease in systemic toxicity, benign local tissue reactions, and diminished burning and irritant effects. Schematic illustration of the sugar-capsaicin prodrug for sensory selective nerve blockade. Sugar-capsaicin prodrugs penetrate the peripheral nerve barrier, mediated by the GLUT transporters. After crossing the peripheral nerve barriers, the inactive prodrug is converted to active capsaicin by hydrolysis of the ester bond. Capsaicin acts selectively on sensory but not motor neurons. [Display omitted] [ABSTRACT FROM AUTHOR]

To identify physiological variables for objectively detecting nociception indicative of intraoperative peripheral nerve block failure. A double-blinded randomized clinical study. A sample of 14 male (40.8 ± 12 kg; mean ± standard deviation) and 16 female (34.3 ± 11.4 kg) client-owned dogs. Dogs were randomly assigned to one of three groups for psoas compartment and proximal sciatic nerve blocks (0.2 mL kg–1 per site): guided bupivacaine (GBB), or saline (GSB) block or a blind bupivacaine block (BBB). Guided blocks were performed using an ultrasound-peripheral nerve locator combination. Premedication consisted of medetomidine 0.01 mg kg–1 and morphine 0.3 mg kg–1. General anaesthesia was induced with propofol and maintained with isoflurane in oxygen. Receiver operator characteristic curve analysis was used to compare actual values and change in values of physiological variables between GSB and GBB. The Youden index and associated criterion for each physiological variable were used to determine an objective measure for nociception. Fisher's exact t test, McNemar's test and Cohen's kappa statistical analysis were used to determine association, differences and inter-score reliability between the objective and subjective scoring for BBB. Cardiovascular variables had good discriminating ability to identify a nociceptive response (p < 0.01). The Youden indices for mean (MAP) and diastolic (DAP) arterial pressure were most reliable in detecting nociception. The highest sensitivity was that of ΔMAP (100%) with good agreement between the subjective and objective scores of Δheart rate or systolic arterial pressure (SAP). The use of ΔMAP, ΔSAP, ΔDAP had the best ability in indicating peripheral nerve block failure (p < 0.001). Blood pressure values can detect a response to surgical stimulus in adequately anaesthetized dogs. The use of ΔMAP, ΔSAP or ΔDAP may be considered as objective measures to detect nerve block failure. [ABSTRACT FROM AUTHOR]

To compare the efficacy of lidocaine administered intravenously, intranasally or as an infraorbital nerve block in dogs undergoing rostral rhinoscopy. Randomized clinical trial. A total of 43 client-owned dogs. After premedication with medetomidine 0.01 mg kg–1 and methadone 0.2 mg kg–1 intramuscularly, anaesthesia was induced with propofol and maintained with isoflurane in oxygen. Dogs were randomly allocated to receive 2 mg kg–1 of 2% lidocaine as a bilateral infraorbital nerve block (INB) via the caudal intraoral approach, via bilateral topical intranasal administration (TIA) or as an intravenous bolus (IVB). At 5 minutes following lidocaine administration, responses to rhinoscopy (RR) and biopsies (RB) were evaluated using a simple scoring system (0: no reaction; 1: reaction). Response to the rhinoscopy in the recovery period (RE) was recorded. Recovery quality was scored using a simple descriptive score. Heart rate, respiratory rate and noninvasive arterial blood pressure were recorded. Intravenous (IV) fentanyl 0.001 mg kg-1 was administered if an increase > 20% in any variable occurred. Gross movement was attenuated using propofol 0.5 mg kg–1 IV. Scores were analysed using the Chi-square test with Monte Carlo method. Cardiorespiratory changes among and overtime between groups were compared using one-way anova and one-way anova for repeated measures, respectively, or the correspondent non-parametric tests; p < 0.05. Of the 43 dogs, 42 completed the study. No statistically significant differences were detected in either physical reactions or changes in cardiorespiratory variables for RR, RB, RE or recovery quality, although RB tended to be higher in group TIA (7/10 versus 1/10 INB and 3/13 IVB).Various cardiorespiratory variables changed overtime within groups. In dogs, all three investigated techniques attenuated responses during rostral rhinoscopy in dogs, although INB and IVB were more efficacious when biopsies were taken. [ABSTRACT FROM AUTHOR]

The efficacy of perineural vs intravenous dexamethasone as a local anaesthetic adjunct to increase duration of analgesia could be particular to specific peripheral nerve blocks because of differences in systemic absorption depending on the injection site. Given this uncertainty, we performed a systematic review with meta-analysis and trial sequential analysis comparing dexamethasone administered perineurally or intravenously combined with local anaesthetic for interscalene brachial plexus block. Following a search of various electronic databases, we included 11 trials (1145 patients). The primary outcome was the duration of analgesia defined as the time between peripheral nerve block or onset of sensory blockade and the time to first analgesic request or initial report of pain. The primary outcome, duration of analgesia, was greater in the perineural dexamethasone group, with a mean difference (95% confidence interval) of 122 (62–183) min, I 2=73%, P <0.0001. Trial sequential analysis indicated that firm evidence had been reached. The quality of evidence was downgraded to low, mainly because of moderate inconsistency and serious publication bias. No significant differences were present for any of the secondary outcomes, except for onset time of sensory and motor blockade and resting pain score at 12 h, but the magnitude of differences was not clinically relevant. There is low-quality evidence that perineural administration of dexamethasone as a local anaesthetic adjunct increases duration of analgesia by an average of 2 h compared with intravenous injection for interscalene brachial plexus block. Given the limited clinical relevance of this difference, the off-label use of perineural administration, and the risk of drug crystallisation, we recommend intravenous dexamethasone administration. PROSPERO (CRD42023466147). [ABSTRACT FROM AUTHOR]

Chronic inflammation in irreversible pulpitis leads to heightened sensitivity of nociceptive receptors, resulting in persistent hyperalgesia. This poses significant challenges in achieving effective anesthesia for patients with irreversible pulpitis. Various anesthetic techniques and pharmacological approaches have been employed to enhance the success of local anesthesia. Recently, the preemptive use of anti-inflammatory agents, specifically corticosteroids, has gained attention and shown promising results in randomized controlled trials. This systemic review and meta-analysis aimed to evaluate the impact of systemically administered corticosteroids on enhancing anesthetic success in patients undergoing endodontic treatment. A comprehensive search was conducted across multiple databases including PubMed, Cochrane Library, Embase, Scopus, Dentistry & Oral Science, and ProQuest. Additionally, the references of primary studies and related systematic reviews were manually searched for additional relevant publications. The primary outcome assessed was the success of anesthesia, and the effect measure was risk ratio using the random-effects inverse variance method. Statistical significance was set at P <.05. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Twelve studies involving 917 participants were analyzed to determine the frequency of successful anesthesia. The corticosteroid group demonstrated a significantly higher number of patients achieving successful anesthesia (risk ratio = 1.66; 95% confidence interval, 1.34–2.06; P <.00001). However, heterogeneity within the pooled data analysis was observed (I 2 = 57%, P =.007). Moderate certainty evidence indicates that preemptive use of systemic corticosteroids enhances the success of local anesthesia, specifically inferior alveolar nerve block, in cases of irreversible pulpitis. [ABSTRACT FROM AUTHOR]

The article delves into perioperative care for patients undergoing total hip arthroplasty, focusing on anesthesia, analgesia, and nerve block techniques. Topics include optimizing outcomes, managing pain effectively, and enhancing recovery after surgery, all crucial for patient well-being and successful procedures.

The nerve block is a safe and effective method to theat trigeminal neuralgia (TN). In terms of the V2 trigeminal neuralgia, the most difficult procedure in nerve block is accurate and fast greater palatine foramen (GPF) insertion. In this study, we developed a new technique using a personalised digital tooth-supported guide plate to increase insertion accuracy and success rates and reduce the pain of patients during injection. A total of 18 patients with TN (11 female and 7 male) were enrolled and treated between September 2020 and June 2022. Before injection, the guide plate was designed via Mimics three-dimensional (3D) reconstruction technology and printed via 3D printer. Then, all patients underwent maxillary nerve block with a guide plate for each injection. In this study, placement of all guide plates was completed within one minute and all punctures were successful the first time. The depth of the injection needle was over 2.5 cm in all cases and the guide plate was stability-supported by the maxillary teeth. The various pain scores had an obvious improvement. No patients presented symptoms of local anaesthetic toxicity or onset of new neurological sequelae. Using this new technology, we can significantly reduce the difficulty of GPF insertion and decrease patient pain during injection. The enhanced success rate of nerve block can achieve better therapeutic effect. For surgeons, personalised digital tooth-supported guide plates make the operation easier, especially for novice surgeons. [ABSTRACT FROM AUTHOR]

Pediatric regional anesthesia has been in existence for over 125 years, but significant progress and widespread use has occurred in the last few decades, with the increasing availability of ultrasound guidance. Evidence supporting the safety of regional anesthesia when performed under general anesthesia has also allowed the field to flourish. Newer techniques allow for more precise nerve blockade and in general this has resulted in more peripheral blocks replacing central blocks, such as caudal epidurals and spinal anesthesia. Current controversial topics in the field include the method of obtaining loss of resistance when placing epidural catheters, the role of regional anesthesia in compartment syndrome and post-hypospadias repair complications, and utility of test doses. [ABSTRACT FROM AUTHOR]

Cutaneous burns are commonly treated with autologous skin grafts. Following skin grafting, many patients complain of pain at the donor site. Donor sites are taken most commonly from the lateral thigh, which is innervated by the lateral femoral cutaneous nerve (LFCN). Use of a LFCN blocks should decrease nociception from the donor site. Our group began utilizing LFCN blocks in 2019. Utilizing anatomic landmarks, LFCN blocks were performed on all patients who received autologous skin grafts to reduce perioperative pain. A retrospective cohort study was performed on all patients with 10% or less total body surface areas burns who received an autologous skin graft. A similar cohort from 2016, prior to use of any local or regional analgesia, was used as a historical control. Post-operative enteral and parenteral narcotic analgesics were collected for each post-operative day up to day 5 or discharge (whichever came first) and converted to morphine milligram equivalents (MME) to quantify analgesia after surgery. Chart review identified 55 patients in the 2020 cohort. Fifty-five patients from the 2016 cohort were matched based upon size of skin graft, total body surface area (TBSA) burned, gender, and age. There were no statistically significant differences between the two groups in terms of size of graft, TBSA burned, age, gender, or type of burn. When examining narcotics usage in the immediate perioperative period (days 0–2), we found no difference between the two groups for total MME (113 vs 133, p = 0.28) or IV MME (38 vs 33, p = 0.45). Similar relationships existed in the extended post-operative period (days 1–5) for total MME (149 vs. 188, t = 0.22) or IV MME (37 vs. 50, t = 0.25). Examining daily narcotic usage also yielded no statistically different values. Our data shows that use of LFCN block by landmark technique did not reduce narcotic usage in patients that undergo skin grafting procedures. Future studies should consider ultrasound-guided LFCN blocks. • Landmark LFCN blocks do not reduce perioperative narcotic usage following skin graft. • In the immediate perioperative period (days 0-2), there was no reduction in total MME or intravenous MME. • There was no difference in narcotic usage in the extended postoperative period (days 1-5). [ABSTRACT FROM AUTHOR]

To assess the safety and efficacy of superior hypogastric nerve block (SHNB) in managing periprocedural pain associated with uterine fibroid embolisation (UFE) and in facilitating same-day discharge. Prospectively enrolled case–control study with retrospective analysis comprising 119 eligible patients who underwent UFE for symptomatic fibroids was undertaken at a UK teaching hospital between January 2016 and September 2022. SHNB was administered to 62 participants in addition to systemic analgesia; 57 participants received systemic analgesia alone. SHNB was performed mid-UFE using 20 ml of 0.25% levobupivacaine. Pain scores were assessed using an 11-point (0–10) verbal numerical rating scale (NRS). The study received research and ethics committee approval. Statistical analysis was performed using the chi-square and independent t -test or Mann–Whitney U -test. A p -value of <0.05 defined significance. Participants who received SHNB experienced significantly less pain during the first 6 h post-procedure (averaged median pain score 2.6 versus 3.8, p =0.031). SHNB reduced the proportion of participants requiring post-procedural anti-emetics (45% versus 63%, p <0.05). For participants entered on the day-case pathway (SHNB = 34, no-SHNB = 16), those who received SHNB had a higher rate of successful same-day discharge (62% versus 31%, p =0.044). This SHNB group required significantly less opioids for periprocedural pain relief (median oral morphine equivalents; 44 mg versus 80 mg, p =0.020). No SHNB-related adverse events occurred. SHNB is safe and effective in reducing perioperative pain, opioid requirements, and anti-emetic use in patients undergoing UFE for symptomatic fibroids. SHNB, as an adjunct to analgesic optimisation, facilitates same-day discharge, which is often limited by severe post-embolisation pain. • Superior hypogastric nerve block (SHNB) is a safe and effective regional anaesthesia. • SHNB reduces pain and opioid requirements post uterine fibroid embolisation (UFE). • The addition of SHNB to an optimised analgesic regime may facilitate day-case UFE. • SHNB can potentially make UFE more cost-effective saving inpatient hospital beds. [ABSTRACT FROM AUTHOR]

The article explores the spread of ultrasound-guided injectate from the adductor canal to the genicular branch of the posterior obturator nerve and the popliteal plexus. Topics include cadaveric study and the predictive value of genicular nerve blocks for cooled radiofrequency ablation outcomes in chronic knee pain due to osteoarthritis.

To compare the success rate and extent of sciatic nerve staining with a bupivacaine–dye solution using two injection techniques: 'blind' or ultrasound-guided approach. Prospective, experimental, randomized, cadaveric study. Adult female Wistar rat cadavers [ n = 24, mass 352 g (323–374)]. Each sciatic nerve was randomly allocated to one of two groups: 'blind' (group B) or ultrasound-guided approach (group US) to injection. Following injection of bupivacaine–dye solution (0.1 mL), gross anatomical dissection was performed to visualize nerve staining, categorizing it as either positive or negative. The length of nerve staining was then measured and visual inspection conducted to identify potential nerve damage. Fisher's exact test was used to compare positive or negative nerve staining, and the Wilcoxon signed rank test used to compare the length of nerve staining between groups. In group B, the bupivacaine–dye solution stained 16/24 sciatic nerves (67% success). In group US, staining was successfully observed in all 24 nerves (100% success, p < 0.004). The length of nerve staining [median (interquartile range)] was 2 (2–3) mm in group B and 5 (4–6) mm in group US (p < 0.001). One sciatic nerve in group B had injectate distributed over 16 mm, suggestive of an intraneural injection. No signs of laceration or nerve damage were visible under 6× magnification in either group. The ultrasound-guided approach for sciatic nerve injection demonstrated a higher success rate with superior injectate distribution when compared with the 'blind' approach. Ultrasound guidance is recommended over a 'blind' approach for sciatic nerve block in rats when possible. [ABSTRACT FROM AUTHOR]

To compare motor effects and analgesic efficacy following an ultrasound-guided lateral approach to lumbar plexus blockade at L7 and sciatic nerve blockade (LPSNB) against epidural injection in dogs undergoing tibial plateau leveling osteotomy (TPLO). Prospective, randomized, blinded clinical trial. A total of 27 healthy adult dogs undergoing unilateral TPLO surgery. Dogs were allocated to either LPSNB (bupivacaine 2 mg kg–1, 0.75%) or epidural (morphine PF 0.1 mg kg–1 and bupivacaine 0.5 mg kg–1, 0.75%). Other aspects of clinical management were identical, including anesthetic drug protocol, area of presurgical clipping and bladder care. Time to perform the block, response to surgical stimuli, pain scores, rescue analgesia, time to stand and walk, motor score and time to first urination were recorded. One evaluator, unaware of treatment status, performed all evaluations. Student's t -test or Mann–Whitney U test was used to compare continuous variables between groups, and Fisher's exact test for categorical variables. Median (range) times to stand and walk were shorter for LPSNB [60 (40–120) minutes and 90 (60–150) minutes, respectively, p = 0.003] than for epidural [150 (120–240) minutes and 180 (120–360) minutes, respectively, p = 0.006]. Four dogs required rescue intraoperatively (three in epidural group, one in LPSNB group, p = 0.438). Pain scores over the 24 hour evaluation period were similar, and not significantly different, for each group. Time to spontaneous urination [LPSNB, 330 (240–360) minutes; epidural, 300 (120–1440) minutes, p = 1.0] did not differ between groups. An ultrasound-guided lateral paravertebral approach to the lumbar plexus within the psoas compartment at L7, combined with sciatic nerve blockade, allows faster return to normal motor function, with similar pain control and impact on urination when compared with epidural in dogs after TPLO surgery. [ABSTRACT FROM AUTHOR]

To coincide with the annual scientific meeting of Regional Anaesthesia UK in London 2024, where there is a joint scientific session with the British Journal of Anaesthesia , a special regional anaesthesia edition of the journal has been produced. This editorial offers some highlights from the manuscripts contained within the special edition. [ABSTRACT FROM AUTHOR]

Histological and micro-ultrasound evidence rebuffs deep-rooted views on the nature of nerve block, nerve damage, and injection pressure monitoring. We propose that the ideal position of the needle tip for nerve block is between the innermost circumneural fascial layer and outer epineurium, with local anaesthetic passing circumferentially through adipose tissue. Thin, circumferential, subepineural expansion that is invisible to the naked eye was identified using micro-ultrasound, and could account for variability of outcomes in clinical practice. Pressure monitoring cannot differentiate between intrafascicular and extrafascicular injection. High injection pressure only indicates intraneural extrafascicular spread, not intrafascicular spread, because it is not possible to inject into the stiff endoneurium in most human nerves. [ABSTRACT FROM AUTHOR]

Superiority of perineural over intravenous dexamethasone at extending nerve block analgesia has been suggested but without considering the dose–response relationships for each route of administration. Randomised control studies that evaluated intravenous or perineural dexamethasone as an adjuvant to unilateral peripheral nerve blocks in adults were searched up to October 2023 in MEDLINE, Central, Google Scholar, and reference lists of previous systematic reviews. The Cochrane Risk-of-Bias tool was used. A maximum effect (E max) model-based network meta-analysis was undertaken to evaluate the dose–response relationships of dexamethasone. A total of 118 studies were selected (9284 patients; 35 with intravenous dexamethasone; 106 with perineural dexamethasone; dose range 1–16 mg). Studies with unclear or high risk of bias overestimated the effect of dexamethasone. Bias-corrected estimates indicated a maximum fold increase in analgesia duration of 1.7 (95% credible interval (CrI) 1.4–1.9) with dexamethasone, with no difference between perineural and intravenous routes. Trial simulations indicated that 4 mg of perineural dexamethasone increased the mean duration of analgesia for long-acting local anaesthetics from 11.1 h (95% CrI 9.4–13.1) to 16.5 h (95% CrI 14.0–19.3) and halved the rate of postoperative nausea and vomiting. A similar magnitude of effect was observed with 8 mg of intravenous dexamethasone. Used as an adjuvant for peripheral nerve block, intravenous dexamethasone can be as effective as perineural dexamethasone in prolonging analgesic duration, but is less potent, hence requiring higher doses. The evidence is limited because of the observational nature of the dose–response relationships and the quality of the included studies. PROSPERO CRD42020141689. [ABSTRACT FROM AUTHOR]

ScanNav TM Anatomy Peripheral Nerve Block (ScanNav™) is an artificial intelligence (AI)-based device that produces a colour overlay on real-time B-mode ultrasound to highlight key anatomical structures for regional anaesthesia. This study compares consistency of identification of sono-anatomical structures between expert ultrasonographers and ScanNav™. Nineteen experts in ultrasound-guided regional anaesthesia (UGRA) annotated 100 structures in 30 ultrasound videos across six anatomical regions. These annotations were compared with each other to produce a quantitative assessment of the level of agreement amongst human experts. The AI colour overlay was then compared with all expert annotations. Differences in human–human and human–AI agreement are presented for each structure class (artery, muscle, nerve, fascia/serosal plane) and structure. Clinical context is provided through subjective assessment data from UGRA experts. For human–human and human–AI annotations, agreement was highest for arteries (mean Dice score 0.88/0.86), then muscles (0.80/0.77), and lowest for nerves (0.48/0.41). Wide discrepancy exists in consistency for different structures, both with human–human and human–AI comparisons; highest for sartorius muscle (0.91/0.92) and lowest for the radial nerve (0.21/0.27). Human experts and the AI system both showed the same pattern of agreement in sono-anatomical structure identification. The clinical significance of the differences presented must be explored; however the perception that human expert opinion is uniform must be challenged. Elements of this assessment framework could be used for other devices to allow consistent evaluations that inform clinical training and practice. Anaesthetists should be actively engaged in the development and adoption of new AI technology. [ABSTRACT FROM AUTHOR]

The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes. [ABSTRACT FROM AUTHOR]

Rebound pain occurs after the resolution of peripheral nerve block and hampers patient recovery in the postoperative period. We sought to synthesise available data from randomised controlled trials (RCTs) evaluating the efficacy of prophylactic dexamethasone for rebound pain in adult patients undergoing surgery with a peripheral nerve block. In this systematic review and meta-analysis, RCTs reporting rebound pain and use of dexamethasone in the context of a peripheral nerve block were searched in various databases and updated in May 2023. The primary outcome was the incidence of rebound pain; secondary outcomes included the severity and time to onset of rebound pain, patient satisfaction with pain control, sleep disturbance because of pain, and adverse effects of dexamethasone. Subgroup analysis was conducted based on the effect of route of administration (intravenous or perineural) on the incidence of rebound pain. Trial sequential analysis was performed to rule out the possibility of a false positive result. Seven RCTs comprising 574 patients were included in this review. The dexamethasone group was associated with a reduction in the incidence of rebound pain with an odds ratio of 0.16 (95% confidence interval 0.10–0.27, P =0.00, I 2=0%) compared with the control group. Trial sequential analysis confirmed the adequate information size for the beneficial effect of dexamethasone. Subgroup analysis showed that both intravenous and perineural administration were associated with a significant reduction in the incidence of rebound pain. Current evidence suggests that both intravenous and perineural dexamethasone reduce the incidence of rebound pain after a peripheral nerve block provided for postoperative analgesia. PROSPERO CRD42023424031. [ABSTRACT FROM AUTHOR]

Lumbar facet syndrome is a cause of pain. The diagnosis iconfirmation is achieved through a selective block. Although this procedure is standardized under fluoroscopic or computed tomography (CT) guidance, the current use of ultrasound may provide an alternative to its implementation. A systematic literature search was conducted. "ultrasound-guided lumbar" and "lumbar facet joint." Twenty articles were included. Five randomized clinical trials, 4 observational studies, 2 clinical trials, 1 retrospective study, 2 metanalysis and 5 cadaveric studies, and 1 feasibility study. The studies demonstrated a improvement in pain with ultrasound. However, no significant differences in these outcomes were found when comparing ultrasound with fluoroscopy or CT. It was also observed that the procedural time was longer with ultrasound. Finally, success rates in correctly locating the injection site ranged from 88% to 100% when confirmed with fluoroscopy or CT. Although the use of ultrasound for regional anesthesia is on the rise, there are no results that can replace those found with fluoroscopy or CT for performing the dorsal and medial branch block of the spinal root in the treatment of lumbar facet syndrome. [ABSTRACT FROM AUTHOR]

A review of the literature was undertaken to determine which amenable factors could be identified that would potentially improve the morbidity or mortality after hip fracture. Only four factors were identified that have been clearly reported to be associated with a reduction in mortality or morbidity, these were early surgery, cemented arthroplasty and experience of the surgeon and peri-operative antibiotics. Five interventions were identified that may reduce mortality or morbidity: nerve blocks, nutritional support, pharmacological thromboembolic prophylaxis, mechanical intermittent pneumatic compression and nail fixation of extracapsular fractures. Several other factors were identified for which it remains uncertain if they will reduce mortality or morbidity: preoperative assessment, β-blockers, blood transfusion, anti-embolism stockings, choice of surgical implant, cardiac output monitoring during surgery, choice of anaesthesia, prevention of intraoperative hypotension, anabolic steroids, multidisciplinary care, and rehabilitation. Continuing research is required to define which interventions are clearly effective and to further identify any adverse effects. [ABSTRACT FROM AUTHOR]

Local anesthesia (LA) training is an essential clinical skill in dental education. However, the traditional teaching method of student-to-student injection has ethical concerns. This study investigated whether a flipped classroom (FC) teaching model with instructional videos improves students' skills in administering LA. Fourth-year dental students in 2017 (traditional teaching, n = 70) and 2018 (FC model, n = 79) were assessed for their ability to perform an inferior alveolar nerve block and lingual nerve block. The FC group watched pre-recorded videos prior to a hands-on training session. Skills were evaluated using a 24-item checklist converted to letter grades. Perceptions of the FC approach were also surveyed. The FC group showed statistically significantly higher final grades than the traditional teaching group (P < 0.05). Most FC students agreed that the videos improved clarity and learning objectives. The FC teaching model with procedural video instruction improved skills and confidence in administering LA over traditional teaching methods. Videos can be a beneficial supplement in pre-clinical dental training. [ABSTRACT FROM AUTHOR]

Ultrasound-guided nerve block anesthesia (UGNB) is a high-tech visual nerve block anesthesia method that can be used to observe the target nerve and its surrounding structures, the puncture needle's advancement and local anesthetics spread in real time. The key in UGNB is nerve identification. With the help of deep learning methods, the automatic identification or segmentation of nerves can be realized, assisting doctors in completing nerve block anesthesia accurately and efficiently. We established a public data set containing 320 ultrasound images of brachial plexus (BP). Three experienced doctors jointly produced the BP segmentation ground truth and labeled brachial plexus trunks. We designed a brachial plexus segmentation system (BPSegSys) based on deep learning. BPSegSys achieves experienced-doctor-level nerve identification performance in various experiments. We evaluated BPSegSys performance in terms of intersection-over-union (IoU). Considering three data set groups in our established public data set, the IoUs of BPSegSys were 0.5350, 0.4763 and 0.5043, respectively, which exceed the IoUs 0.5205, 0.4704 and 0.4979 of experienced doctors. In addition, we determined that BPSegSys can help doctors identify brachial plexus trunks more accurately, with IoU improvement up to 27%, which has significant clinical application value. We establish a data set for brachial plexus trunk identification and designed a BPSegSys to identify the brachial plexus trunks. BPSegSys achieves the doctor-level identification of the brachial plexus trunks and improves the accuracy and efficiency of doctors' identification of the brachial plexus trunks. [ABSTRACT FROM AUTHOR]

To investigate the feasibility of an ultrasound-guided sciatic nerve block by describing the sonoanatomy and comparing the distribution of two volumes of bupivacaine dye solution for nerve staining. Randomized, experimental, assessor-blinded cadaveric study. A total of 40 adult female Wistar rat cadavers. After studying the sonoanatomy of the sciatic nerve and adjacent structures using a high-resolution linear transducer (19–5 MHz), rat cadavers were randomly divided into two groups that were administered either 0.1 mL (group 0.1) or 0.2 mL (group 0.2) of bupivacaine dye solution per nerve, delivered via an in-plane technique. The extent of nerve staining was subsequently evaluated following dissection. Statistical analysis consisted of assessing data distribution using the Shapiro–Wilk test, followed by paired t -tests for continuous data, Mann–Whitney U test and McNemar's test for categorical data. Statistical significance was defined as p < 0.05. The sciatic nerve was identified bilaterally as a double ellipsoid-shaped image, surrounded by a hyperechoic fascia separating the biceps femoris from the adductor muscle. The hypoechoic structure formed by the bupivacaine dye solution around the nerve was effectively visualized using ultrasound imaging. Sciatic nerve staining was successfully achieved in all pelvic limbs, with dye spread of 4.82 ± 1.55 mm and 5.47 ± 2.18 mm in groups 0.1 and 0.2, respectively (p = 0.128). This study achieved a detailed understanding of the sonoanatomy of the sciatic nerve and its adjacent structures, highlighting the feasibility of the ultrasound-guided technique for injection in Wistar rats. Furthermore, the results show a comparable distribution of dye solution in both groups. Use of the ultrasound-guided sciatic nerve block technique in rats not only exhibits substantial potential for regional anesthesia but also opens avenues for translational studies. [ABSTRACT FROM AUTHOR]

Hidradenitis suppurativa (HS) is a painful, chronic inflammatory skin condition. Patients experience exacerbations, leading them to present to the emergency department (ED) for incision and drainage. Direct injection of local anesthetic into these lesions is extremely painful and seldom provides adequate anesthesia. A modified method of the PECS II block can provide anesthesia to the skin of the axilla, making management of HS much less painful for the patient. We performed a bilateral modified PECS II block on a patient requiring incision and drainage of HS lesions in both axillae. She subsequently required no local anesthetic for the procedure. The second injection of the traditional PECS II block involves the deposition of anesthetic in the fascial plane between the pectoralis minor muscle and the serratus anterior muscles. This injection targets the lateral branch of the intercostal nerves, which provide sensory innervation to the axilla. A modified technique of the PECS II block, in which only the second injection is performed, is a potentially effective method for anesthetizing the axilla of patients with HS prior to incision and drainage. [ABSTRACT FROM AUTHOR]

Retrospective Observational Study. Lumbar radicular pain has a prevalence of 3–5%. Level 1 evidence has demonstrated equivalence between surgical and injection treatment. We assess the outcomes from a transforaminal epidural steroid injection clinic in a tertiary neuroscience referral centre. We performed an analysis of data from consecutive patients entered into a new internal referral database between August 2018 to May 2021. Radicular pain was classified as one of "first presentation" or "recurrence". Outcomes were obtained from follow up clinic letters and recorded in a binary manner of "positive result" or "negative result". Spinal pathology was documented from radiology reports and MRI images. We analysed 208 patients referred to the clinic. Excluding those who improved to a point of not requiring treatment, and those who underwent surgical intervention, 119 patients undergoing injection were included, of which 14 were lost to follow-up. 68 % of patients had a positive result from injection. Subgroup analysis demonstrated good outcomes for both hyperacute (<6 weeks) and chronic (>12 months). Contained disk pathologies had better outcomes than uncontained. There was no difference in outcomes across grades of compression, but previous same level surgery was associated with poorer response rates. There is a high rate of natural resolution of symptoms in patients with LSRP. In those where pain persists, TFESI is a valuable first line treatment modality. This study suggests the efficacy of TFESI is potentially independent of grade of stenosis and chronicity of symptoms. Contained disc pathologies respond better than uncontained. • Injection therapy is a cost effective modality in managing lumbosacral radicular pain. • 68 % of patients reported a positive outcome. • Those with a contained disc pathology where more likely to have better outcomes. • There was no correlation between severity of stenosis and outcome from injection. [ABSTRACT FROM AUTHOR]

Breast augmentation is often performed as a day-case general anaesthetic operation, with postoperative, opioid-based analgesia regimens. However, it may also be performed using regional anaesthesia; a variety of nerve block techniques are available to reduce postoperative pain and analgesic requirements. This systematic review and meta-analysis were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines comparing breast augmentation using regional anaesthesia with general anaesthesia, versus general anaesthesia alone or with local field infiltration. All randomised or quasi-randomised studies that recruited adult female patients undergoing breast augmentation using regional anaesthesia were considered. The primary outcome measures were postoperative pain and analgesic requirements. A randomised effects model was used, with standardised mean difference or mean difference outcomes used as appropriate. Thirteen studies were included for systematic review, out of which eight met the inclusion criteria for meta-analysis. Nerve blocks had statistically significant standardised mean difference reductions in postoperative pain scores across all time points: 0 h (−1.2 [−2.1 to −0.3], p = 0.01, I2 = 85%), 1 h (−1.3 [−2.1 to −0.5], p = 0.002, I2 = 89%), 2 h (−1.8 [−2.8 to −0.9], p = 0.0002, I2 = 88%), 4–6 h (−1.2 [−2.1 to −0.4], p = 0.006, I2 = 89%), 24 h (−1.4 [−2.5 to −0.2], p = 0.02, I2 = 94%). There was also a statistically significant reduction in postoperative opioid requirements: −150 mcg fentanyl (−259.2 to −40.9), p = 0.007. Although an element of study heterogeneity is noted, this systematic review and meta-analysis support the concept that regional anaesthesia using nerve blocks in breast augmentation surgery, reduces both postoperative pain and opioid requirements, compared with general anaesthesia. [ABSTRACT FROM AUTHOR]

The first sacral nerve root block (S1 NRB) is used to diagnose and treat lumbosacral and radicular pain. This study aims to clarify the anatomy of the S1 neural foramen using three-dimensional (3D) computed tomography (CT) images and to establish the optimal fluoroscopic angle, localize the S1 neural foramen on fluoroscopy, and determine the safe puncture depth for S1 NRB. In this single-center cohort study, 200 patients with lumbar degenerative disease who underwent preoperative CT were enrolled. Four distinct studies were conducted using the CT data. Study 1 examined the correlation of the sacral slope angle and the supine and prone positions. Study 2 analyzed the tunnel view angle (TVA) using 3D reconstruction. Study 3 ascertained the location of the S1 neural foramen in fluoroscopy images. Study 4 investigated the safe depth for performing S1 NRB. The regression analysis in Study 1 revealed a correlation of the sacral slope angle and the supine and prone positions. Study 2 determined an optimal fluoroscopic TVA of approximately 30° for the S1 NRB. Study 3 found that the S1 neural foramen was located caudal to the L5 pedicle 1.7 ± 0.2 times the distance between the L4 and L5 pedicles. Study 4 revealed that the depths of the S1 neural foramen and root were 27.0 ± 2.1 mm and 16.5 ± 2.0 mm, respectively. Our study suggests an optimal fluoroscopic angle, a simple method to locate the S1 neural foramen on fluoroscopy, and an ideal puncture depth for a safe and effective S1 NRB. [ABSTRACT FROM AUTHOR]

To investigate and describe an extraoral approach to perform a maxillary nerve block in guinea pigs. Prospective, randomized, blinded, descriptive, cadaveric study. A total of 14 adult guinea pig cadavers. Two cadavers were used for anatomic dissection and determination of maxillary nerve block approach. A maxillary nerve block via infraorbital approach was then performed in 12 cadavers. A low volume (0.1 mL) or high volume (0.2 mL) of diluted methylene blue injectate was randomly assigned to the right or left side, with the other volume used for the contralateral side. The maxillary nerve was dissected after each injection by an investigator blinded to injectate volume. The region of dye distribution was identified, and the degree of staining assigned an accuracy score (0–2). Nerve coverage was considered adequate if ≥6 mm of circumferential staining was present. Accuracy evaluation indicated successful dye deposition in 10/12 [2 (0–2), median (range)] injections in the low volume group and 8/12 [2 (1–2)] injections in the high volume group. The majority (79.2%) of injections resulted in adequate nerve staining. There were no statistically significant differences between injectate volumes for accuracy (p = 0.64) or adequacy (p > 0.99) of staining. The infraorbital approach is a simple and practical method for maxillary nerve blockade in guinea pigs. An injectate volume of 0.1 mL results in adequate maxillary nerve coverage; however, additional studies are needed to assess the efficacy in clinical use. [ABSTRACT FROM AUTHOR]

Hip fracture is a common fragility injury in the elderly population, and usually requires early surgical intervention to restore mobility and facilitate rehabilitation. Many of these patients have underlying comorbidities that may pose significant challenges in the perioperative management. A comprehensive preoperative evaluation by a multidisciplinary team for risk assessment and medical optimization is crucial. Multimodal, preferably opioid-sparing, analgesia and regional techniques are useful adjuncts to the mode of anaesthesia. Novel techniques like the pericapsular nerve group block and palliative treatment of hip neurolysis are gaining popularity as alternatives to existing treatments for hip fractures. [ABSTRACT FROM AUTHOR]

Acute pain can have many etiologies that include surgical procedures, trauma (motor vehicle accident), musculoskeletal injuries (rib fracture) and, burns among others. Valuable components of a multimodal approach to acute pain management include both opioid and non-opioid medications, procedure specific regional anesthesia techniques (peripheral nerve blocks and neuraxial approaches), and interventional approaches (eg, peripheral nerve stimulation and cryo-neurolysis). Overall, successful acute perioperative pain management requires a multimodal, multidisciplinary approach that involves a coordinated effort between the surgical team, the anesthesia team, nursing, and pharmacy staff using Enhanced Recovery After Surgery (ERAS) protocols. [ABSTRACT FROM AUTHOR]

This document provides an overview of post-dural puncture headache (PDPH), covering its historical perspective, anatomy and physiology of cerebrospinal fluid (CSF), pathophysiology, risk factors, diagnosis, and treatment options. PDPH is a common complication of dural puncture, characterized by a postural headache due to CSF leakage. The understanding of CSF and dural anatomy has evolved over time, leading to advancements in diagnosing and managing PDPH. Treatment options range from conservative measures to epidural blood patch, intrathecal catheter, and regional techniques like sphenopalatine ganglion block and greater occipital nerve block. Further research is needed to optimize treatment approaches and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Several studies have indicated that reactive oxygen species (ROS) can lead to detrusor overactivity (DO), but the underlying mechanisms are not known. Hydrogen dioxide (H 2 O 2) is used commonly to investigate the effects of ROS. In present study, we investigated the effects of H 2 O 2 on phasic spontaneous bladder contractions (SBCs) of isolated human-bladder strips (iHBSs) and the underlying mechanisms. Samples of bladder tissue were obtained from 26 patients undergoing cystectomy owing to bladder cancer. SBCs of iHBSs were recorded in organ-bath experiments. H 2 O 2 (1μM–10mM) concentration-dependently increased the SBCs of iHBSs. These enhancing effects could be mimicked by an agonist of transient receptor potential (TRP)A1 channels (allyl isothiocyanate) and blocked with an antagonist of TRPA1 channels (HC030031; 10 μM). H 2 O 2 induced enhancing effects also could be attenuated by desensitizing sensory afferents with capsaicin (10 μM), blocking nerve firing with TTX (1 μM), blocking neurokinin effects with NK2 receptor antagonist (SR48968, 10 μM), and blocking PGE2 synthesis with indomethacin (10 μM), respectively. Our study: (i) suggests activation of TRPA1 channels on bladder sensory afferents, and then release of substance P or PGE2 from sensory nerve terminals, contribute to the H 2 O 2 -induced enhancing effects on SBCs of iHBSs; (ii) provides insights for the mechanisms underlying ROS leading to DO; (iii) indicates that targeting TRPA1 channels might be the promising strategy against overactive bladder in conditions associated with excessive production of ROS. [Display omitted] • H 2 O 2 enhances spontaneous contractions of isolated human-bladder strips. • Activation of sensory TRPA1 channels by H 2 O 2 contributes to the enhancing effect. • Release of substance P or PGE2 from sensory nerves mediates H 2 O 2 -enhancing effect. [ABSTRACT FROM AUTHOR]

Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities. [ABSTRACT FROM AUTHOR]

Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n =82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate. [ABSTRACT FROM AUTHOR]

The efficacy of thoracoscopic intercostal nerve blocks (TINBs) for noxious stimulation from video-assisted thoracic surgery (VATS) remains unclear. The efficacy of TINBs may also be different between nonintubated VATS (NIVATS) and intubated VATS (IVATS). We aim to compare the efficacy of TINBs on analgesia and sedation for NIVATS and IVATs intraoperatively. Sixty patients randomized to the NIVATS or IVATS group (30 each) received target-controlled propofol and remifentanil infusions, with bispectral index (BIS) maintained at 40–60, and multilevel (T3–T8) TINBs before surgical manipulations. Intraoperative monitoring data, including pulse oximetry, mean arterial pressure (MAP), heart rate, BIS, density spectral arrays (DSAs), and propofol and remifentanil effect-site concentration (Ce) at different time points. A two way ANOVA with post hoc analysis was applied to analyze the differences and interactions of groups and time points. In both groups, DSA monitoring revealed burst suppression and α dropout immediately after the TINBs. The Ce of the propofol infusion had to be reduced within 5 min post-TINBs in both NIVATS (p < 0.001) and IVATS (p = 0.252) groups. The Ce of remifentanil infusion was significantly reduced after TINBs in both groups (p < 0.001), and was significantly lower in NIVATS (p < 0.001) without group interactions. The surgeon-performed intraoperative multilevel TINBs allow reduced anesthetic and analgesic requirement for VATS. With lower requirement of remifentanil infusion, NIVATS presents a significantly higher risk of hypotension after TINBs. DSA is beneficial for providing real-time data that facilitate the preemptive management, especially for NIVATS. [ABSTRACT FROM AUTHOR]

Acute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation. We report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5–10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement. [ABSTRACT FROM AUTHOR]

Hot-iron disbudding, the practice of cauterizing horn bud tissue to prevent horn growth in dairy calves, results in behavioral changes indicative of pain in the first few days after the procedure. However, few studies have quantified behavioral changes in the following weeks, while the burn wounds are still healing. Female Holstein calves were disbudded with a heated iron and pain relief (5.5 mL lidocaine cornual nerve block and 1 mg/kg oral meloxicam) at 4 to 10 d of age (n = 19) or not disbudded (n = 19). Calves wore ear tag accelerometers that reported the dominant behavior being performed at 1-min intervals from 3 to 21 d after disbudding. Compared with age-matched controls, disbudded calves tended to spend more time inactive throughout the observation period, ruminated less in the first 3 to 11 d after disbudding, and sucked more from a milk bottle beginning 5 d after disbudding until the end of the 21-d observation period. In addition to the accelerometer data, live observations of sleeping (using a behavioral proxy), lying, and ruminating were collected using instantaneous sampling at 5-min intervals for 24-h periods 3, 10, and 17 d after disbudding. Disbudded calves slept with their head down more on all live observation days and spent more time lying on the 17th d after disbudding, but ruminating did not differ compared with controls, in contrast to the accelerometer results. More time spent inactive, sleeping, and lying, and less time spent ruminating (as indicated by the accelerometer) can be interpreted as attempts to reduce painful stimulation of the disbudding wounds and allocate energy to healing. It is unclear whether the greater amount of sucking in the disbudded calves is nutritive (milk present) or non-nutritive (milk absent), as the algorithm did not distinguish the type of sucking, and further research is needed to explore the factors underlying this effect. We conclude that disbudding alters daily behavior patterns for at least 3 wk, far beyond the duration of recommended pain medication, raising additional welfare concerns about the procedure. [ABSTRACT FROM AUTHOR]

One of the most common untoward occurrences during strabismus surgery at all ages is the oculocardiac reflex. Although typically easily treated, the sudden bradycardia or cardiac arrest may add a few gray hairs to ophthalmologists and anesthesiologists alike as it can be potentially fatal. This updated review of the literature and novel detailed treatment algorithm may prevent patient morbidity and mortality through proper recognition of at-risk patients and rapid treatment through proper communication between surgical and anesthesia physicians/providers. • Lessening muscular tension may be accomplished while leaving instruments on the field and moving the eye into primary position. • If suture adjustment is anticipated, special attention should be paid to those with a positive intraoperative OCR. • Volatile anesthetics are associated with a lower incidence of the OCR and may be preferred during ocular surgery. • Total intravenous anesthetic techniques with propofol or remifentanil should be avoided to reduce incidence and severity of OCR. • Peribulbar blockade appears most effective for reduction of OCR incidence compared with other ocular nerve blocks. [ABSTRACT FROM AUTHOR]

Use of augmented reality is increasingly applied in medical education and practice. The main advantage of this technology is the display of relevant information in the visual field of multiple operators. Here we provide a critical analysis of the potential application of augmented reality in regional anaesthesia. [ABSTRACT FROM AUTHOR]