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Background and Aims: Quadratus lumborum block (QLB) is a compartmental block of the anterior abdominal wall. Surgical trauma produces neuroendocrine surgical stress responses, which are modified by anaesthetic blocks. The aim of this study was to evaluate the effect of ultrasound (US)-guided QLB on analgesia and surgical neuroendocrine stress response in paediatric patients undergoing pyeloplasty. Methods: A randomised trial was conducted in 60 children aged 1–7 years undergoing elective open pyeloplasty. Patients were randomised into Group QLB [US-guided QLB with 0.5 ml/kg of 0.25% ropivacaine after induction of general anaesthesia (GA)], and Group GA, which received only GA. Perioperative haemodynamic parameters, serum cortisol, blood glucose, analgesic consumption and postoperative FLACC scores were recorded. Unpaired t-test, Wilcoxon rank-sum test or Mann–Whitney U test was used to compare variables between the two groups. Two-way analysis of variance or the Friedmann test was used to compare quantitative variables at various points within a group. Results: A decrease in serum cortisol and blood glucose values was observed in Group QLB at 30 min after surgical incision and 24 h after surgery compared to the preoperative value and compared to Group GA (P < 0.05). The quality of analgesia assessed by the FLACC scale was significantly better in group QLB. Dose of fentanyl consumption (μg/kg) was higher in Group GA compared to Group QLB in the intraoperative and postoperative period (P < 0.05). Conclusion: QLB is effective as part of multimodal analgesia and attenuates the neuroendocrine stress in paediatric patients undergoing open pyeloplasty.

Background and Aims: Single-shot erector spinae plane block (ESPB) provides excellent analgesia in mastectomy in the immediate post-operative period but is not sufficient to maintain for prolonged duration. This study compares the efficacy of programmed intermittent bolus (PIB) versus continuous infusion (CI) techniques after ESPB by placing a catheter for mastectomy. Methods: After ethical approval and patient consent, ESPB was performed at the T4 level in 50 patients with an initial bolus of 20 mL 0.375% ropivacaine and a catheter placed 30 min before surgery. In the postoperative period, they were randomised to Group I - intermittent bolus of 20 mL 0.2% ropivacaine every 4 h for 24 h and Group C - continuous infusion of 0.2% ropivacaine at 5 mL/h for 24 h. The primary outcome was the 24-h fentanyl consumption by patient-controlled analgesia device. Data was analysed using Stata 14.0. Results: Group I patients had reduced post-operative fentanyl consumption {mean [standard deviation (SD)]: 166 (139.17) μg vs 332 (247.96) μg, P = 0.002} and lower median NRS scores (1 h: 3 vs 5), (2 h: 3 vs 5), (4 h: 3 vs 5), (6 h: 4 vs 5) with a higher mean (SD) Quality of Recovery-15 score {134.4 (8.53) vs 127 (12.89), P = 0.020} compared to Group C, respectively. The 24-h dermatomal sensory coverage was more comprehensive in Group I compared to Group C. Conclusion: The PIB technique after ESPB provides decreased postoperative opioid consumption, better post-operative analgesia and quality of recovery compared to the CI technique in patients undergoing mastectomy.

Background and Aims: Laparoscopic trans abdominal preperitoneal (TAPP) repair of hernia is one of the most commonly performed surgeries and may cause significant postoperative pain. Among different truncal block techniques, quadratus lumborum (QL) and transversus abdominis plane blocks (TAP) are used during this abdominal surgery. We aimed to investigate whether, bilateral QL block by trans-muscular approach provided better analgesia as compared to posterior TAP block in these patients. Methods: Forty adult patients with American Society of Anesthesiologists physical status I and II, undergoing inguinal hernia repair were randomized to receive either QL or TAP block, with 20 mL of 0.25% ropivacaine bilaterally. The primary objective of the study was to compare the total fentanyl consumption (in μg) within 24 hours postoperatively. The secondary objectives studied were dermatomal spread, quality of recovery at discharge and at 3 months postoperatively. Results: There was a significant reduction in total 24-hour fentanyl consumption (552 ± 229.56 vs 735.5 ± 264 μg, P =0.01) in the QL group, with longer duration of analgesia [282.5 ± 89.9 min group TAP vs. 354.8 ± 107 min QL, (mean difference -72.34,95% confidence interval -135.516 to -9.024), P =0.03], as compared to TAP group. At T8 and T9 dermatomes, greater proportion of patients in the QL group attained analgesia. Quality of Recovery at 24 hours and at 3 months of follow-up were comparable. Conclusion: QL block provided better perioperative analgesia than TAP block, in patients undergoing laparoscopic hernia repair. It also leads to greater dermatomal spread but without any decrease in the incidence of chronic pain at 3 months postoperatively.

Background and Aims: Analgesia for hip surgery involves cutaneous anaesthesia at the site of the skin incision and the anterior hip capsule. This study aimed to compare continuous ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) with psoas compartment block (PCB) for analgesia in patients undergoing total hip arthroplasty (THA) under general anaesthesia (GA). Methods: This randomised, observer-blinded trial included 18–70-year-old American Society of Anesthesiologists physical status I–III patients undergoing THA under GA with either US-guided continuous TQLB or PCB. Primary objectives included a visual analogue scale (VAS; 0–100 mm) at rest and mobilisation at 6 h postoperatively (analysed by intention to treat and per protocol) using a non-inferiority margin of 20 mm. Secondary objectives included VAS at other time points, 24-h fentanyl consumption (analysed using the Wilcoxon rank-sum test), sensory dermatomes anaesthetised, motor weakness 30 min after block, and haemodynamic response to skin incision (analysed using the Chi-squared or Fisher's exact test). A P value less than 0.05 was considered statistically significant. Results: VAS (0-100 mm) score at 6 h on rest was 25.34 ± 14.25 and 27.3 ± 9.6, mean difference (MD) was 1.9 [−3.3, 7.1] and at movement was 35.1 ± 23.0 and 38.6 ± 17.0, MD was 3.5 [−5.2, 12.2], in the PCB (n = 29) and QLB (n = 30) groups, respectively (i.e. less than the non-inferiority margin). However, VAS (rest) at 1, 12, and 24 h postoperatively and median (IQR) 24-h fentanyl consumption was significantly higher in the QLB group (1212.5 [300–2345] μg] when compared to the PCB group (635 [100–1645] μg; P = 0.0004). Conclusion: Though statistically, continuous QLB was non-inferior to continuous PCB for pain at rest and mobilisation at 6-hours postoperatively, a higher 24-hour perioperative fentanyl consumption and VAS show that QLB was clinically inferior to PCB.

Abstract Background Quadratus lumborum block has been claimed to provide effective analgesia in abdominal surgeries by covering both somatic as well as visceral pain. However, its utility in morbidly obese patients has not been reported or evaluated. Case presentation In this case report, of laparoscopic hernia repair in a morbidly obese patient (weight 110 kg, height 1.53 m, BMI 46.9 kg/m2), there was excellent perioperative analgesia with no rescue opioid consumption in intraoperative period and average VAS score of 3 in 24 h postoperatively. The first recue analgesic was administered in the form of intravenous (IV) diclofenac 75 mg (diluted in 100 ml normal saline) 12 h after surgery when the patient reported a VAS of 5. Conclusions QL block is an effective, feasible, and safe option for providing analgesia for laparoscopic hernia repair in morbidly obese patients.

Background and Aims: Serratus anterior plane (SAP) blocks can be given either superficial or deep to the serratus anterior muscle to block the branches of intercostal nerves providing analgesia to the anterolateral chest wall. This prospective randomised comparative study aimed to compare the analgesic efficacy of superficial and deep SAP block in breast surgeries. Methods: Forty female patients scheduled to undergo elective modified radical mastectomy under general anaesthesia (GA) were randomly assigned to receive ultrasound guided SAP block with 30 ml 0.375% ropivacaine either superficial (group S, n = 20) or deep (group D, n = 20) to the serratus anterior muscle, before the induction of GA. The primary outcome was post operative fentanyl requirement over 24 hours and secondary outcomes were comparison of numerical rating scale (NRS) scores for pain, sensory block mapping, time to perform the block, number of needle attempts, etc. Results: The post operative 24-hour fentanyl requirement was comparable between group S and D (318.75 ± 80.65 versus 272.5 ± 80.25 μg, P = 0.07). NRS pain scores were comparable between the groups. Sensory block mapping done at various levels showed T3–T7 block in most of the patients with no difference between the groups. Block performance time (6.05 ± 3.27 versus 8.35 ± 3.26 minutes, P = 0.034) and number of needle attempts was significantly lesser in group D. Conclusion: There was no difference in analgesic efficacy when SAP block was given superficial or deep to serratus anterior muscle for modified radical mastectomies. However, deep SAP block required less time and number of attempts to perform than superficial technique.

Postamputation phenomenon is commonly encountered in more than 80% of amputees. Due to the increasing burden of trauma and associated amputations, disability due to postamputation pain becomes rampant. In this review, we aim to describe the history, epidemiology, types and mechanisms of postamputation phenomenon, factors affecting its development, and the currently available treatment modalities – both pharmacological and nonpharmacological.

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive soft-tissue tumor with a high recurrence rate, often requiring multiple surgeries with multiple sessions of radiotherapy that alters the anatomy and makes regional anesthesia challenging in these patients. The multiple injection costotransverse block (MICB) is a type of “paravertebral by proxy” block in which the drug is injected within the thoracic intertransverse tissue complex with spread to the paravertebral space without any epidural spread. Unlike the traditional approach to paravertebral block, which involves piercing the superior costotransverse ligament, the MICB has a shallower needle trajectory making needle visualization easier and the more superficial needle tip location reduces the chances of a pleural puncture and subcostal vessel injury. We present the case of a 51-year-old male with recurrent DFSP in the anterior axillary fold who was posted for tumor debulking. As the sonoanatomy was altered due to multiple previous surgeries and radiotherapy, we chose to perform an ultrasound-guided MICB.

Background: Facet joint (FJ)-mediated pain is one of the frequent causes of low back pain. Fluoroscopy and computed tomography guided medial branch blocks (MBBs) are accepted as standard techniques to diagnose FJ arthropathy. Ultrasound-guided (USG) MBB can be an alternative approach for the diagnostic MBB in FJ arthropathy. This study evaluates the feasibility of USG MBB in FJ arthropathy and validates by fluoroscopy. Materials and Methods: Diagnostic USG MBBs were performed in sixty patients. Two medial branches were targeted for each FJ. The needle was inserted in an in-plane technique after identifying the desired site. The needle position was confirmed by fluoroscopy. Pain scores were assessed before and after the nerve block. Results: Out of 161 needle insertions, 139 needles (86.3%) were at the radiologically defined target point as confirmed by fluoroscopy and were labeled as successful. Mean baseline, immediately before, immediately after, and at 24 h, Numeric Rating Scale (NRS) scores were 7.53 (0.93), 7.02 (0.93), 3.03 (1.75), and 2.80 (1.99), respectively (P < 0.05). The mean Modified Oswestry Disability Questionnaire scores before and 24 h after block were 48.77 (8.94) and 32.55 (11.32), respectively. Fifty-three patients had ≥60 points on the 100-point scale given by Helbig, and out of these patients, 44 patients had a ≥50% reduction in the NRS score. Conclusion: Diagnostic USG lumbar MBBs, a minimally invasive procedure without radiation exposure, can be performed with a high success rate in FJ arthropathy.

Background and Aims: Enhanced recovery after cardiac surgery is centred around multimodal analgesia which is becoming increasingly feasible with the advent of safer regional analgesic techniques such as fascial plane blocks. We designed this prospective, single-blind, randomised controlled study to compare the efficacy of serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for post-thoracotomy analgesia in cardiac surgery. Methods: 100 adults posted for cardiac surgery through a thoracotomy were randomly allocated to one of the three groups: SAPB, Pecs II or, ICNB wherein the patients received 2.5 mg/kg of 0.5% ropivacaine for ultrasound-guided block after completion of surgery. Postoperatively, intravenous (IV) paracetamol was used for multimodal and fentanyl was employed as rescue analgesia. Visual analogue scale (VAS) was evaluated at 2, 4, 6, 8, 10 and 12 hours post-extubation. Results: The early mean VAS scores at 2, 4 and 6 hours were comparable in the 3 groups. The late mean VAS (8, 10 and 12 hours) was significantly lower in the SAPB and Pecs II group compared with that of the ICNB group (P value

Background: Thoracic paravertebral block (TPVB) has become the gold standard to provide postoperative analgesia in breast surgery. Recently, ultrasound-guided (USG) pectoralis (PECS) block and serratus anterior plane (SAP) block have been described as an alternative to TPVB. The objectives were to compare TPVB, PECS, and SAP block in terms of analgesic efficacy and the spread of local anesthetic by ultrasound imaging, correlating it with the sensory blockade. Materials and Methods: Prospective randomized interventional study conducted in 45 ASA grades I–II patients scheduled for the elective breast surgery. Patients were randomly allocated into three groups, i.e., Gr.1 (USG –TPVB) (ropivacaine 0.375% 20 ml), Gr.2 (USG-PECS II) block (ropivacaine 0.375% 30 ml), and Gr.3 (USG-SAP) (ropivacaine 0.375% 30 ml). Spread of the local anesthetics was seen with ultrasound imaging. Onset of sensory blockade, postoperative fentanyl consumption, and pain scores was measured. Results: TPVB and SAP group had comparatively higher spread and sensory block compared to PECS group. Postoperative fentanyl requirement (mean ± SD) was 428.33 ± 243.1 μg, 644.67 ± 260.15 μg, and 415 ± 182.44 μg in the TPVB group, PECS II group, and SAP group, respectively. SAP group had significantly lesser requirement than PECS II group (P = 0.028) but similar requirement as in TPVB group (P = 1.0). Pain scores were not significantly different among the group in the postoperative period. Conclusion: TPVB and SAP group result in a greater spread of the drug and provide equivalent analgesia and are superior to the PECS II block in providing analgesia for breast surgeries. SAP block is easier to perform than TPVB with lesser chances of complications and results in faster onset.

Hepatobiliary surgeries are associated with severe pain, and coagulopathy. Adequate pain control is vital and difficult to achieve for these patients. Epidural analgesia is considered the routine standard technique for the management of both somatic and visceral pain from major abdominal surgeries until now. However, it is invasive, blind and carries the risk of dural or vascular puncture. Coagulopathy found in patients posted for hepatobiliary surgery further increases the concerns. We found ultrasound guided erector spinae plane block as a safe, simple yet an effective alternative to epidural analgesia for postoperative pain management of hepatobiliary surgeries. Keywords: Erector Spinae Block, Thrombocytopenia, Hepatic surgery

The postoperative pain management in open thoracotomy is very crucial as the effective analgesia can prevent respiratory and thrombotic complications and lead to early mobilization and discharge. The thoracic epidural analgesia is the gold standard in such surgeries; however, there are few adverse effects such as hypotension, dural puncture, and contralateral block that always warrants safer alternative. Recently, with the advent of ultrasound, the regional anesthetic techniques are getting more popular to avoid such complications. Erector spinae plane (ESP) block is one of the novel techniques that has been described as a safe thoracic paravertebral block. We are reporting here the continuous ESP block as a primary mode of postoperative analgesia which was continued for 48 h. The intraoperative opioid requirement was very less, and the maximum NRS score in postoperative period was 4 at 12 h, which was well managed with multimodal analgesic regimen along with rescue doses of opioid.

Postoperative pain after breast surgery is difficult to manage owing to its complex innervation. Recently, erector spinae plane (ESP) block, an interfacial block, has been described to provide pain relief after thoracic and abdominal surgeries, multiple rib fractures, and neuropathic thoracic pain. Local anesthetic injected in the erector spinae muscle sheath at the level of the 5th thoracic transverse process is distributed cranially and caudally along the sheath, and to the paravertebral space through apertures in the anterior sheath wall. This may block the dorsal and ventral rami of the thoracic spinal nerves at multiple vertebral levels and the rami communicantes transmitting autonomic fibers to and from the sympathetic ganglia, causing multidermatomal somatic and visceral analgesia. The present case report demonstrates the adequate perioperative analgesia provided by the ultrasound-guided ESP block in patients undergoing various breast surgeries.

Trigeminal neuralgia (TN) is one of the most painful conditions occurring in the face. It causes sudden, severe, unilateral, sharp, stabbing, or burning pain along the distribution of the trigeminal nerve. Antiepileptic and analgesic medications are the primary choices of therapy. Peripheral trigeminal nerve block is a beneficial treatment option during the acute paroxysmal period of TN in patients who have contraindications or are refractory to pharmacological management. TN at V2 (maxillary) area is reported to account for 37.8% of all TN cases, and 80% of TN at V2 can be treated with infraorbital nerve block. Ultrasound imaging is helpful in localizing the infraorbital foramina for giving superficial trigeminal nerve block. In this case series, we performed real-time ultrasound-guided infraorbital nerve block which is a branch of the maxillary division of the trigeminal nerve. All patients had satisfactory pain relief.

Regional anesthetic techniques have gradually revolutionized the perioperative analgesia in breast surgeries. Recently, midpoint transverse process to pleura block has been described and found to provide excellent opioid-sparing analgesia. We performed the block in a novel out-of-plane technique to decrease the patient-needle interaction time and at the same time achieving good analgesia. The immediate postoperative Numeric Pain Rating Scale score was 0/10 both at rest and on movement, and patient reported a score of 5/10 after 12 h, which get subsided with single dose of nonopioid analgesic.

Factor XI deficiency is a rare coagulation disorder associated with bleeding tendency and prolonged APTT. Parturients can have increased bleeding during vaginal delivery or cesarean section. Patients with severe factor XI deficiency should receive prophylactic fresh frozen plasma or factor XI transfusion in the peripartum period to maintain a near normal APTT. Limited evidence based on case reports and series is inconclusive as to the choice of anesthesia technique for cesarean section. We describe the anesthesia management of a parturient with severe factor XI deficiency for cesarean section and discuss the relevant literature.