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INTRODUCTION Post operative pain is the most common complaint in post anaesthesia care units (PACU). Lower abdominal surgeries are associated with severe post-operative pain and inadequate post-operative analgesia leads to many complications. Multimodality approach is used to treat postoperative pain. Transversus abdominus plane (TAP) block is a peripheral nerve block of the trunk that provides analgesia between T10 to L1 dermatomes with a single injection which was first described by A.N. Rafi 1 in 2001 . TAP Block is indicated in any lower abdominal surgeries. Local anaesthetic is deposited in the fascial sheath between the internal oblique and transverse abdominis muscle using either the blind or the ultrasound guided technique. Adjuvants are frequently used in regional analgesia for rapid onset to improve the quality and prolong the duration of block. Alpha 2 agonist dexmedetomidine speeds the onset of block and prolongs duration of analgesia. Aim : To assess whether addition of dexmedetomidine to ropivacaine may bring some improvements to the analgesic efficacy and quality of TAP blocks in patients undergoing appendicectomy surgeries . MATERIALS AND METHODS 30 Patients belonging to ASA Class I or II scheduled for appendicectomy were selected for the study . The patients were randomized into two groups: Group R - receiving plain ropivacaine (2ml of normal saline and 20ml 0.2%ropivacaine) Group R+D - receiving ropivacaine with dexmedetomidine (0.5 mcg /kg of dexmedetomidine dissolved in 2ml of normal saline and 20ml 0.2%ropivacaine). At the end of surgery, USG guided transversus abdominus plane block was performed. Results Addition of dexmedetomidine to ropivacine in TAP block lower pain scores after 3hrs in postoperative period and the same trend of analgesia continued for the first 24 hours. It confers better post operative analgesia with less analgesic requirement and adverse effects. Conclusion: The addition of dexmedetomidine to ropivacaine in TAP block confers better pain control and decreases the total dose of analgesics post-operatively without any major side-effect

Objective: Since initial description by Forero for thoracic region, ultrasound guided erector spinae plane (ESP) block has experienced several surgeries for postoperative pain management, chronic pain or surgical anesthesia. Although ESP block has been reported to provide effective analgesia in the thoracic region, its effect in lumbar region still unclear. In this study we aimed to showed our successful experience with lumbar ESP block as a main anesthetic technique in fifteen high risk elderly patients undergoing hip surgery with mild propofol sedation. Materials and Methods: In this observational study high risk elderly fifteen patients received lumbar ESP block as a main anesthetic technique with mild propofol sedation. 40 mL of local anesthetic mixture (20 mL bupivacaine 0.5%, 10 mL lidocaine 2%, and 10 mL normal saline) was administered between the erector spinae muscles and transverse process at the level of the 4th lumbar vertebra. Also we demonstrate magnetic resonance images and discuss the anatomic basis of lumbar ESP block. Results: All patients' surgeries were completed without requirement for general anesthesia or local anesthesia infiltration of the surgical site. All patients' pain scores were

Interscalene brachial plexus blockade is the most common regional anaesthesia technique for alleviating pain after shoulder surgery, but complications occur, including ipsilateral hemidiaphragmatic paresis, Horner's syndrome and hoarseness. The supraclavicular approach might be an effective alternative with fewer adverse effects.The aim of this study was to determine whether there is a difference in postoperative pain scores and morphine equivalents between interscalene and supraclavicular brachial plexus blocks. Secondary endpoints were serious adverse events.A systematic review and meta-analysis of randomised controlled trials.A comprehensive literature search of Embase, CENTRAL, MEDLINE and Web of Science was performed from the earliest record to December 2018.Prospective randomised controlled trials that compare interscalene and supraclavicular brachial plexus blocks in patients undergoing shoulder surgery were eligible for inclusion. Only studies that reported their methods transparently and comprehensibly were included. Conference abstracts or meeting abstracts were not excluded a priori. Risk of bias was assessed using Cochrane methodology.Twelve studies were eligible for meta-analysis. The supraclavicular approach showed overall comparable 24-h pain scores (mean difference -0.34; 95% CI -0.75 to 0.07, P = 0.11) and comparable morphine equivalent consumption (mean difference 1.84 mg per 24 h; 95% CI -0.00 to 3.69, P = 0.05). Secondary endpoint analysis revealed a significantly lower rate of hemidiaphragmatic paresis (risk ratio 0.56; 95% CI 0.39 to 0.82, P = 0.003) and Horner's syndrome (risk ratio 0.29; 95% CI 0.19 to 0.44, P 0.00001) for the supraclavicular approach. There was no significant difference in hoarseness (risk ratio 0.73; 95% CI 0.48 to 1.13, P = 0.16).After 24 postoperative hours, pain scores and consumption of morphine equivalents were comparable. Adverse effects were less common with the supraclavicular approach. The supraclavicular approach might be an efficient alternative to the interscalene approach for shoulder surgery. However, the available evidence is inadequate and prevents a firm conclusion.

To the Editor:Cervical plexus block (CPB) is used to treat postoperativepain after various head and neck surgeries1, and this regionalanaesthesia technique may also be a good choice for painmanagement following orthognathic surgery. We report ourexperience of ultrasound-guided superficial cervical plexusblock in a patient who underwent bilateral sagittal splitosteotomy.

Objective. We aim to report our experiences regarding the implementation of the ultrasound-guided combined interscalene-cervical plexus block (CISCB) technique as a sole anesthesia method in clavicular fracture repair surgery. Materials and Methods. Charts of patients, who underwent clavicular fracture surgery through this technique, were reviewed retrospectively. We used an in-plane ultrasound-guided single-insertion, double-injection combined interscalene-cervical plexus block technique. During the performance of each block, the block areas were visualized by using a linear transducer, and the needles were advanced by using the in-plane technique. Block success and complication rates were evaluated. Results and Discussion. 12 patients underwent clavicular fracture surgery. Surgical regional anesthesia was achieved in 100% of blocks. None of the patients necessitated conversion to general anesthesia during surgery. There were no occurrences of acute complications. Conclusions. The ultrasound-guided combined interscalene-cervical plexus block was a successful and effective regional anesthesia method in clavicular fracture repair. Prospective comparative studies would report the superiority of the regional technique over general anesthesia.

BACKGROUND The addition of adjuncts like Neostigmine, opioids, midazolam, dexmedetomidine, hyaluronidase, clonidine etc., to local anaesthetics for brachial plexus block may enhance the quality and duration of analgesia. Fentanyl, a phenylpiperidine derivative, is known to produce antinociception and enhance the effect of local anaesthetics when given epidurally or intrathecally. The purpose of the present study is to assess the effect of fentanyl added to brachial plexus block by axillary approach. MATERIALS AND METHODS A prospective, randomized, single blinded study was conducted on 100 patients of either sex, belonging to 15-55 years of age. ASA grade I and II admitted to Osmania General Hospital for upper limb surgeries from 2015-2017 were operated under axillary approach of brachial plexus block. Patients were randomly divided into two groups. Patients in Group B (n = 50) were administered 40 ml of 0.25% Bupivacaine and Group BF (n = 50) were given 40mL of 0.25% Bupivacaine with preservative free fentanyl 2.5 µg/ml. The onset time and duration of sensory and motor blockade were recorded. Haemodynamic variables (i.e., heart rate, blood pressure and oxygen saturation), sedation scores and rescue analgesic requirements were recorded for 24 hrs. postoperatively. RESULTS The duration of sensory and motor block was significantly longer in Group BF compared to Group B (p

ZusammenfassungAusgewählte Regionalanästhesieverfahren sind für den ambulant tätigen Anästhesisten eine attraktive Alternative zu Analgosedierung und Narkose – und dies bei hoher Patientenzufriedenheit und seltenen Komplikationen. Dieser Beitrag widmet sich den organisatorischen und hygienischen Anforderungen, die es dabei zu beachten gilt. Des Weiteren gehen die Autoren auf einzelne Verfahren und ihre Anwendung in unterschiedlichen Körperregionen näher ein.

István Molnár,1 Gabriella Hegyi,1,2 Lajos Zsom,3 Christine Saahs,4,5 Jan Vagedes,6,7 Gábor Kapócs,8 Zoltán Kovács,1 Martin-Günther Sterner,9 Henrik Szőke1,2 1Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; 2Department of CAM, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; 3Department of Nephrology, Fresenius Medical Care, Cegléd, Hungary; 4Department of Pediatrics, University of Vienna, Vienna, Austria; 5Pediatric Outpatient Department, Krems, Austria; 6University Children’s Hospital, University of Tuebingen, Tuebingen, Germany; 7Department of Complementary and Integrative Medicine, ARCIM Institute (Academic Research in Complementary and Integrative Medicine), Filderstadt, Germany; 8Department of Psychiatry and Psychiatric Rehabilitation, Saint John Hospital, Budapest, Hungary; 9Department of Medical Clinics I, Klinikum Niederlausitz, Lauchhammer, Germany Background: Pancreatic cancer is a malignant disease with a high mortality rate and severe pain that is challenging to manage. To reduce the excruciating abdominal pain, opioids and adjuvant agents are conventionally used.Objectives: PRNCPB is a treatment of neural therapy. The number of studies assessing the effect on patients’ QoL is limited and inconsistent. With this study, we intended to address this issue.Study design: A prospective nonrandomized study with a series of cases of unresectable pancreatic cancer was conducted.Setting: The study was performed at our pain clinic under real life conditions.Materials and methods: A total number of 16 patients with severe abdominal pain were enrolled in the study all of whom had responded to combined systemic analgesic therapy inadequately and had intolerable side effects contraindicating further increase in dose. The efficacy of this invasive, palliative analgesic procedure was evaluated 35 days after PRNCPB was performed. Primary outcomes were changed in pain intensity using the VAS questionnaire. Secondary outcomes were improved in QoL using the SF-36 questionnaire. Changes in pain medications and adverse reactions were monitored.Results: After PRNCPB patients experienced a significant decrease (P=0.002) in pain intensity as shown by the VAS score, and a decreased opiate demand. Their QoL scores considering effect sizes also improved (P

Purpose This study was conducted to test whether blocking the serotonin receptors by intravenous [IV] ondansetron; can help in reducing the hypotensive bradycardic events [HB events] associated with shoulder arthroscopy done in the sitting position under interscalene plexus block [ISB]. Methods One hundred and fifty patients, scheduled for shoulder arthroscopy in the sitting position under ISB, were randomly assigned to one of three groups receiving either: 4 mg ondansetron, or 8 mg ondansetron or saline. Results IV injection of ondansetron 4 mg or 8 mg significantly reduced the incidence of HB events from 20.4% in the saline group to 6.1% after injection of 4 mg ondansetron and 6% after injection of 8 mg ondansetron; p value [0.030]. Conclusion IV ondansetron either 4 mg or 8 mg reduces the HB events during shoulder arthroscopy in the sitting position under ISB.

Background/Purpose: An improvement of the blood flow would be beneficial in microvascular upper-extremity reconstruction and in digit replantation. In the present work, skin perfusion changes and their duration due to axillary plexus block were quantified. Methods: The peripheral blood flow of the upper extremities in 20 patients undergoing trapeziectomy under axillary plexus block was analyzed. Results: Laser Doppler spectrophotometry was used to measure perfusion factors over a 12-h period, with the contralateral hand acting as the control. Axillary plexus block produced a significant increase of peripheral oxygen saturation (117 ± 35% vs. control 93 ± 22%, p = 0.019), peripheral blood flow (220 ± 166% vs. 130 ± 77%, p = 0.037), and velocity (164 ± 58% vs. 117 ± 45%, p = 0.011). Conclusion: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremities over the first 6 h after the inception of anesthesia. This suggests a potential benefit especially for critically perfused tissues.

Bei einem 73-jahrigen Patienten wurde im Rahmen einer ultraschallgesteuerten Anlage eines Interskalenusblocks fur eine Schulterarthroskopie der Zufallsbefund einer zystischen Struktur in der Schilddruse erhoben. In der Abklarung konnte die Diagnose einer Schilddrusenmetastase eines 10 Jahre zuvor resezierten Nierenzellkarzinoms gestellt werden. Bei jeder ultraschallgesteuerten Nervenblockade sollte die betreffende Region vor Punktion systematisch untersucht werden, um die anatomischen Strukturen zu beurteilen und um Normvarianten oder pathologische Befunde nicht zu ubersehen.

The goal of the current study was to compare the quality of esophageal speech and voice to videofluoroscopic features of the esophagus and pharyngoesophageal (PE) segment. The speech and voice characteristics of 30 laryngectomized patients were rated by 5 speech-language pathologists. Based on these ratings, patients were divided into 3 categories: fluent (n = 9), moderately fluent (n = 10) and nonfluent (n = 11). Videofluoroscopy of the PE region was then performed during both swallowing and voice production. An insufflation test and percutaneous pharyngeal plexus block were required in 9 patients to determine the etiology of poor esophageal voice production. The strongest videofluoroscopic indicators of nonfluent speakers were: (1) small or absent air reservoir and (2) lack of a vibrating PE segment. Fluent speakers presented with shorter PE segments (1.17 mm) compared to moderately fluent speakers (17.1–29.9 mm). Perceptually, fluent speakers presented with a predominantly rough vocal quality. In contrast, moderately fluent speakers presented with a tense quality. In addition, stoma blast noise was reduced in fluent speakers. Videofluoroscopic findings highly correlated with the quality of esophageal speech.

Introduction : Intravenous Regional Anesthesia (IVRA) has been first described in 1908 by the German surgeon August KG Bier. Although the technique was convenient to perform and effective in giving surgical anesthesia, the recent plexus block techniques have largely replaced the “Bier’s block” instantly because of time limitations and safety considerations of IVRA. Throughout the years, modifications in procedure and new pharmacologic adjuvants have shown to prevent toxic reactions to anesthetics and mitigate limitations of IVRA, still IVRA can be preferred as choice of anesthesia for short procedures. Case Report : We present a case of 86 yr old male who was operated for radius fracture after a fall injury under Bier’s Block or IVRA technique. Conclusion : IVRA can be the choice of anesthesia for short procedures because of rapid onset of anesthesia, easy administration and cheaper cost with special considerations on its side effects, complications which can be the outcome of technical errors. DOI: https://doi.org/10.22502/jlmc.v3i1.65

We compared the success rate of single-injection infraclavicular plexus block by using electrically evoked radial, ulnar, or median nerve-type distal motor response to guide the injection of local anesthetic.Consecutive patients requiring surgery distal to the upper arm were prospectively included in this study over a 6-month period. No search for predetermined distal motor responses was performed. The first qualifying distal motor response evoked for a stimulating current intensity of0.5 mA distributed patients into 3 groups of patients. The study was continued until 3 groups of 60 patients were fulfilled. Twenty to 25 minutes after the injection of 30 mL of 1.5% mepivacaine, blinded evaluation of block quality was performed. A successful block was defined by the presence of a complete sensory block of the 5 major nerve distal distributions of the arm.Five hundred patients were included. The first evoked distal motor response was of radial, median, and ulnar nerve type in 46% (n = 230), 42% (n = 210), and 12% (n = 60) cases, respectively. The success rate of the infraclavicular plexus block was significantly higher when the injection was performed on a radial nerve-type response (90%) as compared with the median (74%) or ulnar (68%) nerve distal motor response. Intraoperative sedation and general anesthesia were not needed. None of the patients experienced specific complications.We showed that evoked distal motor response influenced the success rate of single-injection infraclavicular plexus block. The highest success rate was obtained when injection was performed after radial nerve-type motor response.

In patients with chronic end-stage liver disease, the peak plasma concentrations of ropivacaine after a single intravenous ropivacaine dose are similar to those in healthy subjects. However, patients with end-stage liver disease have about a 60% lower mean ropivacaine clearance than healthy subjects and are thus expected to have over two-fold higher steady-state ropivacaine plasma concentrations during a continuous ropivacaine infusion. The peak plasma concentrations of ropivacaine after an axillary plexus block in uraemic patients are considerably higher than those in non-uraemic patients. However, uraemic patients have significantly higher alpha-1-acid glycoprotein plasma concentrations than non-uraemic patients, and the peak plasma concentrations of free ropivacaine (related to toxicity) are similar in both groups. The pharmacokinetics of intravenously administered ropivacaine in patients with renal insufficiency and the possibility of clinically significant (S)-2',6'-pipecoloxylidide metabolite accumulation during continuous or repeated ropivacaine administration in these patients remain to be clarified.

To make regional anesthesia work in an environment where increasing pressure is exerted to do more procedures in less time, providers strive to find new ways to increase the speed of anesthetic delivery. After the completion of an epidural, nerve, or plexus block, it seems that one has little control over the time required for the development of anesthesia. To influence this latency period, investigators study adjuvants with the hope of discovering one that will hasten this process. This article reviews the additives and manipulations that have been tried to facilitate the onset of peripheral nerve block, epidural anesthesia, intravenous regional anesthesia, and peribulbar block.

Background The effects of the infraclavicular plexus block using the modified Raj approach on diaphragm and respiratory function have not been investigated. Methods After obtaining approval of the local ethics committee and written informed consent, 20 patients, scheduled for surgery of the forearm, wrist, or hand were prospectively included. Infraclavicular block was performed using the modified Raj technique with 40 to 50 mL ropivacaine 0.5%. Forced diaphragmatic excursion (DE), vital capacity (VC), first-second forced expiratory volume (FEV1), and peak expiratory flow rate (PEFR) were assessed the day before surgery and 30 and 360 minutes after blocks, respectively. Results There was no significant difference between pre- and postblock values, neither for DE (5.6 ± 1.0 cm before the block, 5.2 ± 1.4 cm 30 minutes after the block, and 5.7 ± 1.4 cm 360 minutes after the block) nor for VC (3.2 ± 0.8 L before the block, 3.1 ± 0.9 L 30 minutes after the block, and 3.0 ± 0.9 L 360 minutes after the block), FEV1 (2.8 ± 0.9 L before the block, 2.8 ± 0.9 L 30 minutes after the block, and 2.7 ± 0.9 L 360 minutes after the block), or PEFR (378 ± 116 L/min before the block, 355 ± 110 L/min 30 minutes after the block, and 364 ± 116 L/min 360 minutes after the block). Conclusion Infraclavicular block using the modified Raj technique did not interfere with diaphragmatic excursion or respiratory function.

Nowadays, microvascular reconstructions are performed with high success rate even in small children. The combination of general anaesthesia and axillary plexus block was used in this prospective study in order to achieve optimal surgical conditions in these challenging operations. Fifteen children under eight years of age (1-8 years) were anaesthetised with a standardised anaesthesia method using a combination of general anaesthesia and axillary plexus block for microvascular toe-to-hand transfer. The duration of anaesthesia varied between 7.5-14.5 hours (mean 11 h). The difference in peripheral skin temperature was used to indicate the difference in peripheral circulation. Due to plexus block, the mean skin temperature in the operated hand was 1.4 degrees C higher than in the opposite extremity at the end of the operation. In the early postoperative phase the temperature difference increased to 4.8 degrees C (P < 0.01) due to vasoconstriction in the control hand. The mean temperature in the transplant was 33.3 +/- 2.4 degrees C at the end of the operation. Primary microvascular results were good in all but two children who needed reoperations. All of the transfers survived. The mean central temperature increased progressively during the operation from 36.2 degrees C to 37.6 degrees C. One 1-year-old child developed a moderate hyperthermia of 39.1 degrees C. According to this study axillary plexus block can be combined with general anaesthesia in prolonged microvascular operations. When the effect of general anaesthesia ceased, the plexus block effectively increased peripheral circulation in the operated hand.

The aim of this study was to evaluate axillary injection of fentanyl into the brachial plexus using the axillary approach. Twenty-six patients, aged 2 to 11 years (ASA I and II), undergoing upper limb surgery, participated in the study. They were divided into two groups: Group 1 (n=15) received 2 μg kg−1 fentanyl and Group 2 (n=11) received saline only. All patients received inhalational general anaesthesia. The interval between onset of anaesthesia and pain was 809 minutes for Group 1 and 199 minutes for Group 2.