Ultrasound-guided continuous costoclavicular block through retrograde stimulating catheter technique for postoperative analgesia in shoulder surgery: a case series

Abstract In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Early versus late sphenopalatine ganglion block with ropivacaine in postdural puncture headache: an observational study

Abstract Background Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients' discharge. Sphenopalatine ganglion block (SPGB) is a safe bedside technique with comparable efficacy to Epidural Blood Patch, the gold-standard treatment. There is no evidence on the ideal timing for SPGB performance. We aimed to evaluate the difference between early versus late SPGB concerning efficacy, symptom recurrence and hospital length of stay. Methods We present an observational study with 41 patients diagnosed with PDPH who were submitted to SPGB with ropivacaine 0,75%. The study sample (n = 41) was divided in two groups: an early (less than 24 hours after diagnosis) and a late (more than 24 hours after diagnosis) SPGB group. Pain was evaluated 15 minutes after the block and follow up occurred daily until patients were discharged. Patients' demographic characteristics, neuraxial technique, timing of SPGB, qualitative pain relief and post-SPGB length of stay were registered and analyzed with SPSS statistics (v26) software. Results Early SPGB resulted in a significant reduction in length of stay (p = 0,009) and symptom recurrence (p = 0,036), showing equally effective pain relief, compared to late SPGB. Conclusions SPGB was equally effective in both groups. Data showed that early SPGB reduces length of hospital stay and symptom recurrence, which potentially allows early resumption of daily activities and a reduction in total health costs.

Analgesic effect of intercostal nerve block given preventively or at the end of operation in video-assisted thoracic surgery: a randomized clinical trial

Abstract Objective To compare the analgesic effect of intercostal nerve block (INB) with ropivacaine when given preventively or at the end of the operation in patients undergoing video-assisted thoracic surgery (VATS). Methods A total of 50 patients undergoing VATS were randomly divided into two groups. The patients in the preventive analgesia group (PR group) were given INB with ropivacaine before the intrathoracic manipulation combined with patient-controlled analgesia (PCA). The patients in the post-procedural block group (PO group) were administered INB with ropivacaine at the end of the operation combined with PCA. To evaluate the analgesic effect, postoperative pain was assessed with the visual analogue scale (VAS) at rest and Prince Henry Pain Scale (PHPS) scale at 6, 12, 24, 48, and 72 hours after surgery. Results At 6 h and 12 h post-surgery, the VAS at rest and PHPS scores in the PR group were significantly lower than those in the PO group. There were no significant differences in pain scores between two groups at 24, 48, and 72 hours post-surgery. Conclusion In patients undergoing VATS, preventive INB with ropivacaine provided a significantly better analgesic effect in the early postoperative period (at least through 12 h post-surgery) than did INB given at the end of surgery.

Effects of intrathecal injection of ropivacaine on spinal cord in rats based on genomics / 中南大学学报(医学版)

OBJECTIVES@#There are clinical reports of nerve injury caused by ropivacaine. The mechanism for nerve injury induced by ropivacaine has not been fully clarified. This study aims to investigate the changes of pain threshold and L3 spinal cord genomics at 6 h and 24 h after intrathecal injection of 0.5% and 1.0% ropivacaine, and to explore the underlying mechanisms for nerve injury caused by ropivacaine.@*METHODS@#A total of 30 male Sprague Dawley rats weighing 220-260 g were successfully implanted with microspinal catheter. The rats were randomly divided into 5 groups (each n=6): a control group (given saline), a ropivacaine group 1 and a ropivacaine group 2 (both given 1% ropivacaine), a ropivacaine group 3 and a ropivacaine group 4 (both given 0.5% ropivacaine). The rats received continuous intrathecal injection of corresponding drugs at 8.3 μL/h for 24 h via an implanted intrathecal catheter followed by 24 h-pause of injection for the ropivacaine group 2, the ropivacaine group 4 and the control group, 6 h-pause of injection for the ropivacaine group 1 and the ropivacaine group 3. For each group, the observation of behavioral change and the paw withdrawal mechanical threshold (PWMT) was conducted immediately after the injection and again after the pause of injection. After the PWMT observation, the rats were dissected to acquire L3 spinal cords. Illumina sequencing was applied to construct gene libraries. Then the statistical methods were used to find out differentially expressed genes between the groups. Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) signaling pathway analysis were conducted for those genes. Real-time RT-PCR was used to determine different expressions of some of those genes.@*RESULTS@#Compared with control group, the PWMT got higher in the ropivacaine group 1-4 and was positively correlated with concentration, negatively correlated with discontinuation duration. Compared with control group, the ropivacaine group 1 had 488 differentially expressed genes, of which 456 were up-regulated and 32 were down-regulated; the ropivacaine group 2 had 1 194 differentially expressed genes, of which 1 092 were up-regulated and 102 were down-regulated; the ropivacaine group 3 had 518 differentially expressed genes, of which 384 were up-regulated and 134 were down-regulated; and the ropivacaine group 4 had 68 differentially expressed genes, of which 46 were up-regulated and 22 were down-regulated. GO enrichment analysis and KEGG signaling pathway analysis showed that most of these differentially expressed genes were related to signaling pathways of inflammatory response.@*CONCLUSIONS@#After intrathecal injection of 0.5% ropivacaine and 1.0% ropivacaine for 24 h, the differentially expressed genes in L3 spinal cord of rats are mainly related to signaling pathways of inflammatory response.

Analgesic effect of ropivacaine after arthroscopic reconstruction of the ligament in athletes / Efeito analgésico da ropivacaína após reconstrução artroscópica do ligamento em atletas / El efecto de la ropivacaína en el dolor después de la reconstrucción artroscópica de ligamentos de un atleta

ABSTRACT After arthroscopic ligament reconstruction, athletes still need to go through a postoperative rehabilitation training period and suffer the possible pain that can go from moderate to severe. Commonly used analgesic medications, ropivacaine and fentanyl have the effect of relieving athletes' pain. To study the analgesic effect of ropivacaine on arthroscopic reconstruction of the knee ligament, the steps of reconstruction and pharmacology of ropivacaine were first introduced. Next, the analgesic effects of ropivacaine and fentanyl in 86 athletes were compared on muscle strength recovery, patient satisfaction, and pain score. The results showed that the satisfaction of patients with ropivacaine was 95.35%, and the incidence of postoperative adverse reactions was only 9.30%. These results indicate that ropivacaine has a better analgesic effect in arthroscopic reconstruction of the knee ligament in athletes, which is suitable for postoperative rehabilitation.

RESUMO Após a reconstrução artroscópica do ligamento, os atletas ainda precisam passar por um longo período de treinamento pós-operatório de reabilitação e suportar a possível dor de moderada a severa. Os medicamentos analgésicos ropivacaina e fentanilo comumente utilizados têm o efeito de aliviar a dor dos atletas. Para estudar o efeito analgésico da ropivacaína na reconstrução artroscópica do ligamento do joelho foram introduzidos, em primeiro lugar, os passos da reconstrução artroscópica do ligamento e os da farmacologia da ropivacaína. Em seguida, os efeitos analgésicos da ropivacaína e o fentanilo em 86 atletas foram comparados com a recuperação na força muscular, na satisfação do paciente e na pontuação da dor. Os resultados mostraram que a satisfação dos doentes com a ropivacaína chegava a 95.35%, e a incidência de reações adversas pós-operatórias foi apenas de 9.30%. Estes resultados indicam que a ropivacaína tem melhor efeito analgésico na reconstrução artroscópica do ligamento do joelho, o que é adequado para a reabilitação pós-operatória.

RESUMEN Después de la reconstrucción artroscópica del ligamento, los atletas aun precisan pasar por un largo período de entrenamiento posoperatorio de rehabilitación y soportar el posible dolor que puede ir de moderado a severo. Los medicamentos analgésicos, ropivacaína y fentanilo que son comúnmente utilizados, tienen el efecto de aliviar el dolor de los atletas. Para estudiar el efecto analgésico de la ropivacaína en la reconstrucción artroscópica del ligamento de la rodilla fueron introducidos, en primer lugar, los pasos de la reconstrucción y de la farmacología de la ropivacaína. Enseguida, los efectos analgésicos de la ropivacaína y el fentanilo en 86 atletas fueron comparados en la recuperación de la fuerza muscular, en la satisfacción del paciente y en la puntuación del dolor. Los resultados mostraron que la satisfacción de los pacientes con la ropivacaína llegaba a 95.35%, y la incidencia de reacciones adversas posoperatorias fue apenas de 9.30%. Estos resultados indican que la ropivacaína tiene mejor efecto analgésico en la reconstrucción artroscópica del ligamento de la rodilla de los atletas, lo que es adecuado para la rehabilitación posoperatoria.

Effects of auriculopalpebral nerve block on ocular parameters in dogs

The objective of this study was to compare the effects of two local anesthetics used on auriculopalpebral block on eyelid akinesia, tear production, intraocular pressure (IOP) and tear break-up time (TBUT) in conscious dogs. A blind, randomized, prospective study was conducted to determine the effects of auriculopalpebral block using ropivacaine 0.75% and bupivacaine 0.5% in 12 healthy non-brachycephalic dogs (24 eyes). Threat response and eyelid reflex tests, Schirmer tear test (STT), IOP and tear break-up time were conducted before blockage and at 30, 60, 120, 240 and 360 minutes after application. A difference was observed between the values found at 30, 60, 120 and 240 minutes compared to baseline for threat response and eyelid reflex tests in the two groups evaluated, proving eyelid akinesia after blockages. No difference was found for STT, IOP and TBUT between baseline values and post-anesthesia times or between groups. It was possible to conclude that ropivacaine and bupivacaine on auriculopalpebral block in conscious dogs promoted eyelid akinesia for at least 240 minutes, not altering ocular physiological parameters of tear production, intraocular pressure, and tear break-up time after blockages.

Roux-in-y gastrojejunal bypass: which anesthetic technique has best results? / Bypass gastrojejunal em y-de-roux: que técnica anestésica apresenta melhores resultados?

ABSTRACT Background: As the number of bariatric operations increases, there is a greater interest in knowledge, experience and skills in the operative and anesthetic management of obese people. Anesthetic recovery is an important point in the therapeutic approach and less adverse effects delaying discharge of these patients are necessary to be kept in mind by the surgical team. Aim: To compare anesthetic-analgesic techniques in the opioid-sparing era through epidural administration of local anesthetic associated with low-dose morphine vs. clonidine and analyze the impact of analgesia on the effectiveness of postoperative recovery by comparing these two techniques. Methods: Randomized, double-blind clinical trial with 66 patients candidates for Roux-en-Y gastrojejunal bypass divided into two groups: morphine group and clonidine group. Multimodal analgesia included epidural anesthesia with 0.375% ropivacaine 20 ml at the eighth thoracic vertebra with the association of morphine (morphine group) at a dose of 15 mcg / kg or clonidine (clonidine group) at a dose of 1 mcg / kg. Results: The groups were homogeneous and statistical significance was found when analyzing the difference in pain between them in the first postoperative period. The pain was higher in the clonidine group, as in this period, analgesic rescue was also better in this group. In the other times, there was no significance in the differences regarding pain and rescue. The return of intestinal motility in the morphine group was earlier in the first postoperative period. Nausea, vomiting and hospital discharge did not show significant differences between groups. Conclusion: Epidural anesthesia with low-dose morphine allowed less pain during the entire hospital stay, with a positive impact on patient recovery.

RESUMO Racional: Com o aumento do número de operações bariátricas torna-se maior o interesse pelo conhecimento, experiência e habilidades no manejo operatório e anestésico de obesos. A recuperação anestésica é ponto importante na abordagem terapêutica e menos efeitos adversos que retardem a alta são necessários estar em mente da equipe cirúrgica. Objetivo: Comparar técnicas anestésico-analgésicas na era poupadora de opioides através da administração epidural de anestésico local associado à morfina em baixa dose vs. à clonidina e analisar o impacto da analgesia na efetividade da recuperação pós-operatória comparando as duas técnicas. Métodos: Ensaio clínico randomizado e duplo-cego com 66 pacientes candidatos ao bypass gastrojejunal em Y-de-Roux divididos em dois grupos: grupo morfina e grupo clonidina. A analgesia multimodal incluiu na anestesia epidural com ropivacaína 0,375% 20 ml na altura da oitava vértebra torácica a associação de morfina (grupo morfina) em dose de 15 mcg/kg ou de clonidina (grupo clonidina) na dose 1 mcg/kg. Resultados: Os grupos se mostraram homogêneos e foi encontrada significância estatística ao analisar a diferença da dor entre eles no primeiro pós operatório. A dor foi superior no grupo clonidina, como também neste período o resgate analgésico foi melhor neste grupo. Nos demais tempos não houve significância nas diferenças quanto à dor e resgate. O retorno da motilidade intestinal no grupo morfina foi mais precoce no primeiro pós-operatório. Náuseas, vômitos e a alta hospitalar não apresentaram diferenças significativas entre os grupos. Conclusão: A anestesia epidural com morfina em baixa dose permitiu menor dor durante todo internamento com impacto positivo em relação a recuperação dos pacientes.

Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial / Comparação entre morfina subaracnoidea e bloqueio do nervo femoral para analgesia após reconstrução ligamentar de joelho: estudo clínico randomizado

Abstract Background and objectives There are no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia. Method Randomized and controlled clinical trial of patients undergoing reconstruction of the Anterior Cruciate Ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The groups C, M, R0,375 and R0,25 was compared with only the previously described technique, subarachnoid morphine (100░µg), or Femoral Nerve Block (BNF) with 25░mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24░hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated. Results Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24░hours. There was a higher incidence of urinary retention in the M group (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 group (30%) than in the M and C groups (0%), with statistical significance (p░<░0.05). Conclusion There was no difference in the intensity of postoperative pain in patients submitted to ACL reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M group and motor block in the R0,375 group.

Resumo Justificativa e objetivos Não há consenso sobre qual é a técnica ideal para prover analgesia em reconstruções ligamentares de joelho. Objetivou‐se comparar a intensidade da dor pós‐operatória desses pacientes sob diferentes modalidades de analgesia. Método Ensaio clínico randomizado e controlado de pacientes submetidos à reconstrução do ligamento cruzado anterior com tendões flexores entre dezembro de 2013 e 2014. Todos os pacientes foram submetidos a raquianestesia e analgesia de resgate com tramadol. Compararam‐se os grupos C, M, R0,375 e R0,25; aos quais se ofertou apenas a técnica anteriormente descrita, morfina subaracnóidea (100 µg) ou bloqueio de nervo femoral com 25 mL de ropivacaína 0,375% e 0,25%, respectivamente. Avaliou‐se intensidade da dor em 6, 12 e 24 horas, idade, sexo, analgesia de resgate, reações adversas e satisfação. Resultados Entre os 83 pacientes elegíveis, observou‐se predomínio do sexo masculino (85,7%) entre 28 e 31 anos. O Grupo C solicitou mais opioide (27,3%) do que os demais grupos, sem significância quando comparados. Não houve diferenças significativas na intensidade da dor em 6, 12 e 24 horas. Houve maior incidência de retenção urinária no Grupo M (23,8%) do que no R0,375 (0%) e de bloqueio motor prolongado do quadríceps no Grupo R0,375 (30%) do que nos Grupos M e C (0%), com significância estatística (p< 0,05). Conclusão Não houve diferença na intensidade da dor pós‐operatória nos pacientes submetidos à reconstrução de ligamento cruzado anterior com tendões flexores sob as modalidades analgésicas avaliadas, apesar do predomínio de retenção urinária no Grupo M e bloqueio motor no Grupo R0,375.

Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report / Bloqueio do plexo cervical como técnica anestésica alternativa para tireoplastia tipo I: relato de caso

Abstract Background: The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. Case report: A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. Conclusion: The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Resumo Introdução: O papel da tireoplastia tipo I (TPI) está bem estabelecido no tratamento de insuficiência glótica após a paralisia das pregas vocais, mas o manejo anestésico ideal para a TPI ainda é controverso. Descrevemos uma nova técnica anestésica para a TPI usando o Bloqueio do Plexo Cervical (BPC) superficial e o BPC intermediário associados, em presença de analgo-sedação leve e intermitente. Relato de caso: Paciente de 51 anos de idade com paralisia da prega vocal esquerda e apneia obstrutiva do sono foi agendada para TPI. BPC intermediário guiado por ultrassom foi realizado usando acesso posterior, e 15 mL de ropivacaína a 0,5% foram injetados no espaço cervical posterior entre o músculo esternocleidomastoideo e a fáscia prevertebral. A seguir, para o BPC superficial, 10 mL de ropivacaína a 0,5% foram injetados na região subcutânea adjacente à borda posterior do músculo esternocleidomastoideo, sem transfixar a fáscia de revestimento. Analgo-sedação intermitente com infusão alvo-controlada de remifentanil (alvo de 0,5 ng.mL-1) foi usada para facilitar a inserção da prótese e a laringoscopia com fibra ótica. A técnica ofereceu via aérea segura durante a anestesia, boa condição para o cirurgião, possibilidade de monitorar a voz, além de ótimo conforto à paciente. Conclusões: O uso de anestesia regional é uma técnica promissora para o cuidado anestésico durante a TPI, especialmente em pacientes com via aérea comprometida.

Bloqueio motor e sensitivo da lidocaína ou da ropivacaína peridural em cães / [Motor and sensitive blockade provided by epidural lidocaine or ropivacaine in dogs]

Objetivou-se avaliar o bloqueio sensitivo e motor da administração peridural de 0,2mL/kg de duas concentrações de ropivacaína em comparação à lidocaína em cães. Utilizaram-se 24 cães, distribuídos em quatro grupos: NaCl a 0,9% (GS), lidocaína a 2% (GL), ropivacaína a 0,5% (GR5) e ropivacaína a 0,75% (GR7,5). Avaliaram-se a presença de movimentação espontânea, deambulação, sensibilidade superficial e profunda nos momentos cinco, 10, 15, 20, 25, 30, 45, 60, 90, 120, 180, 240 e 300 minutos após peridural. O retorno à movimentação espontânea foi semelhante entre GL (42,50 ± 6,12) e GR7,5 (69,2 ± 58,9). O tempo para deambulação foi mais prolongado em GR7,5 (107,5 ± 79,3) que em GS (9,2 ± 3,8) e em GR5 (32,5 ± 20,9). O retorno da sensibilidade profunda foi maior em GR 7,5 (152,5 ± 89,2) que em GS (5,8 ± 2,0), GR5 (46,7 ± 46,3) e GL (52,5 ± 20,7). O tempo de retorno da sensibilidade superficial foi maior em GR7,5 (205,0 ± 129,3) que em GS (7,5 ± 2,7), GL (72,5 ± 19,9) e GR5 (97,5 ± 55,1). Apesar do retorno precoce da movimentação, ropivacaína 0,75% está relacionada a tempo prolongado de recuperação da função muscular e bloqueio sensitivo mais prolongado que lidocaína e ropivacaína 0,5%.(AU)

The aim of the present study was to evaluate the sensory and motor blockade of epidural 0.5% and 0.75% Ropivacaine or Lidocaine in dogs. Twenty-four dogs were distributed in four groups: 0.9% NaCl (GS), 2% lidocaine (GL), 0.5% ropivacaine (GR5) and 0.75% ropivacaine (GR7.5). Spontaneous movement, ability to walk, superficial, and deep pain response were assessed 5, 10, 15, 20, 25, 30, 45, 60, 90, 120, 180, 240 and 300 minutes after epidural. Time to return to spontaneous movement was similar between GL (42.50 ± 6.12) and GR7.5 (69.2 ± 58.9). Time to return to ambulation was longer in GR7.5 (107.5 ± 79.3) than in GS (9.2 ± 3.8) and GR5 (32.5 ± 20.9). Time to recover deep sensitivity was longer in GR 7.5 (152.5 ± 89.2) than in GS (5.8 ± 2.0), GR5 (46.7 ± 46.3) and GL (52.5 ± 20.7). Time to return superficial sensitivity was longer in GR7.5 (205.0 ± 129.3) when compared to GS (7.5 ± 2.7), GL (72.5 ± 19.9) and GR5 (97.5 ± 55.1). Despite the early return of spontaneous movement, 0.75% ropivacaine is related to longer periods for muscle function recovery and longer sensory block than lidocaine and 0.5% ropivacaine.(AU)

Ropivacaine withdrawal syndrome: a case report / Síndrome de abstinência de ropivacaína: relato de caso

Abstract Introduction and objectives: Ropivacaine is a long-acting local anesthetic that causes prolonged anesthesia and is beneficial for a wide variety of surgeries. Systemic toxicity has been reported after usage of high dose ropivacaine or inadvertent intravascular administration. We report a case of ropivacaine withdrawal, which to our knowledge has not been previously described in the literature. Case report: The patient presented to our department with uncontrolled belt-like upper-abdominal pain, self-rated as a 9/10 on the numeric rating scale. We decided to use continuous epidural analgesia with ropivacaine through a multi-port epidural catheter. Pain was well controlled for one month without significant adverse effects. However, ropivacaine unexpectedly ran out and two hours later the patient developed agitation, generalized tremor, tachycardia, and tachypnea. These symptoms resolved 30 minutes after reinitiating epidural ropivacaine. Discussion: Our hypothesis of ropivacaine withdrawal was related to the timing of symptoms in relation to drug administration over two episodes. The possible mechanism of the observed withdrawal syndrome is upregulation of voltage-gated sodium channels after prolonged inhibition, resulting in increase in sodium influx and genetic variation.

Resumo Justificativa e objetivos: A ropivacaína é um anestésico local de ação prolongada indicado em uma ampla variedade de cirurgias. Toxicidade sistêmica tem sido relatada após o uso de dose alta de ropivacaína ou administração intravascular inadvertida. Relatamos um caso de crise de abstinência de ropivacaína que, até onde sabemos, não foi descrita anteriormente na literatura. Relato do caso: O paciente procurou nosso departamento com dor não controlada abdominal do tipo em cinta, avaliada pelo paciente como sendo 9/10 no escala de avaliação numérica. Decidimos usar analgesia peridural contínua com ropivacaína através de cateter peridural multiperfurado. A dor foi bem controlada por um mês sem efeitos adversos significativos. No entanto, a ropivacaína inesperadamente se esgotou e, duas horas depois, o paciente desenvolveu agitação, tremor generalizado, taquicardia e taquipneia. Esses sintomas regrediram completamente 30 minutos após o reinício da ropivacaína por via peridural. Discussão: Nossa hipótese de abstinência de ropivacaína foi relacionada à cronologia dos sintomas em relação à administração da droga ao longo de dois episódios. O possível mecanismo da síndrome de abstinência observada é a regulação positiva dos canais de sódio dependentes de voltagem após inibição prolongada, resultando em aumento do influxo de sódio e variação genética.

Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo

Abstract Background and objectives: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. Methods: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. Results: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale numerical rating scale (NRS) at 24 hours did not differ between groups. Conclusions: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Resumo Justificativa e objetivos: O aparecimento frequente de paralisia hemidiafragmática durante o bloqueio interescalênico restringe seu uso em pacientes com insuficiência respiratória. O bloqueio supraclavicular pode ser uma opção segura e eficaz. Nosso objetivo primário foi avaliar a incidência de paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom e compará-lo com o bloqueio interescalênico. Métodos: Os adultos agendados para cirurgia eletiva do ombro sob anestesia regional (Hospital Universitário de Toulouse) foram prospectivamente incluídos neste estudo observacional, de maio de 2016 a maio de 2017. Vinte mililitros de ropivacaína a 0,375% foram injetados, preferencialmente objetivando a interseção da primeira costela e da artéria subclávia. A excursão diafragmática foi medida por ultrassonografia antes e 30 minutos após a anestesia regional. Uma redução ≥ 25% na excursão diafragmática durante um sniff test definiu a paralisia hemidiafragmática. Dispneia e hipoxemia foram registradas na sala de recuperação. Fatores preditivos de paralisia hemidiafragmática (sexo, idade, peso, tabagismo, capacidade funcional) foram explorados. A dor pós-operatória também foi avaliada. Resultados: Quarenta e dois e 43 pacientes dos grupos bloqueio supraclavicular e bloqueio interescalênico, respectivamente, foram avaliados. A incidência de paralisia hemidiafragmática foi de 59,5% no grupo bloqueio supraclavicular em comparação com 95,3% no grupo bloqueio interescalênico (p < 0,0001). O movimento paradoxal do diafragma foi mais comum no grupo bloqueio interescalênico (RR = 2, 95% IC 1,4-3; p = 0,0001). Uma variação semelhante na saturação de oxigênio foi registrada entre os pacientes com e sem paralisia hemidiafragmática (p = 0,08). Nenhum fator preditivo de paralisia hemidiafragmática pôde ser identificado. O consumo de morfina e o maior escore na escala numérica (NRS) em 24 horas não diferiram entre os grupos. Conclusão: Devido à frequente incidência de paralisia hemidiafragmática após bloqueio supraclavicular, essa técnica não pode ser recomendada para pacientes com função respiratória alterada.

Evaluation of the efficacy of ropivacaine injection in the anterior and middle scalene muscles guided by ultrasonography in the treatment of Thoracic Outlet Syndrome

SUMMARY A clinical, placebo-controlled, randomized, double-blind trial with two parallel groups. OBJECTIVE to evaluate the efficacy of ropivacaine injection in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome (TOS) compared to cutaneous pressure. METHODS 38 patients, 19 in the control group (skin pressure in each belly of the anterior and middle scalene muscles) and 19 in the intervention group (ropivacaine). Subjects with a diagnosis of Nonspecific Thoracic Outlet Syndrome, pain in upper limbs and/or neck, with no radiculopathy or neurological involvement of the limb affected due to compressive or encephalic root causes were included. The primary endpoint was functionality, evaluated by the Disabilities of the Arm, Shoulder, and Hand - DASH scale validated for use in Brasil. The time of the evaluations were T0 = before the intervention; T1 = immediately after; T2 = 1 week; T3 = 4 weeks; T4 = 12 weeks; for T1, the DASH scale was not applied. RESULTS Concerning the DASH scale, it is possible to affirm with statistical significance (p> 0.05) that the intervention group presented an improvement of functionality at four weeks, which was maintained by the 12th week. CONCLUSION In practical terms, we concluded that a 0.375% injection of ropivacaine at doses of 2.5 ml in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome helps to improve function.

RESUMO Ensaio clínico, controlado por placebo, aleatorizado, duplo-cego, com dois braços paralelos. OBJETIVO Avaliar a eficácia da injeção de ropivacaína em cada ventre dos músculos escalenos anterior e médio, guiada por ultrassonografia, no tratamento da Síndrome do Desfiladeiro Torácico Neurogênico inespecífico comparado com o toque cutâneo. MÉTODOS Trinta e oito pacientes, sendo 19 no grupo controle (toque cutâneo em cada ventre dos músculos escalenos anterior e médio) e 19 no grupo intervenção (ropivacaína). Foram incluídos sujeitos com diagnóstico de Síndrome do Desfiladeiro Torácico Neurogênico inespecífico com dor em membros superiores e/ou cervicalgia sem radiculopatia ou comprometimento neurológico do membro em questão por causas radiculares compressivas ou encefálicas. O desfecho primário foi a funcionalidade avaliada pela escala Disabilitie of the Arm, Shoulder and Hand - Dash, validada no Brasil. O tempo das avaliações foram T0 = antes da intervenção; T1 = imediatamente após, T2 = 1 semana, T3 = 4 semanas e T4 = 12 semanas, sendo que para o T1 não foi aplicado o Dash. RESULTADOS Com relação ao Dash, de forma estatisticamente significante (p>0,05), é possível afirmar que o grupo intervenção apresentou melhora da funcionalidade a partir de quatro semanas, e essa melhora se manteve até a 12a semana. CONCLUSÃO Em termos práticos, conclui-se que a injeção de ropivacaína 0,375% nas doses de 2,5 ml em cada ventre dos músculos escalenos anterior e médio, guiada por ultrassonografia, no tratamento da Síndrome do Desfiladeiro Torácico Neurogênico inespecífico auxilia na melhora da função.

Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine / Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Abstract Background and objectives: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. Methods: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30 mL saline, Group R - ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 µg.kg-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. Results: The mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. Conclusion: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Resumo Justificativa e objetivos: O alívio inadequado da dor após a reconstrução do ligamento cruzado anterior afeta a mobilidade, leva ao desenvolvimento de aderências, inserção do ligamento enfraquecido e atrofia muscular. O bloqueio do canal adutor para analgesia pós-operatória preserva a força do quadríceps. O presente estudo foi feito para comparar o período sem dor em pacientes de reconstrução artroscópica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaína isolada e ropivacaína + clonidina. Métodos: Um estudo prospectivo, randômico e duplo-cego foi conduzido com 63 pacientes adultos, estado físico ASA I-II, submetidos à reconstrução do ligamento cruzado anterior. Os pacientes foram randomizados em três grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solução salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375% e 1 µg.kg-1 de clonidina. O desfecho primário do estudo foi comparar o período sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaína isolada ou ropivacina + clonidina. Os desfechos secundários foram escores de dor em repouso e movimento, necessidade total de analgésicos, escore de sedação, além de náusea e vômito no pós-operatório. Resultados: Os períodos médios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferença foi estatisticamente significativa (p < 0,001). Não houve diferença significativa entre os grupos R e RC em termos de escores de dor em repouso e movimento e a necessidade total de analgésicos. Conclusão: A adição de clonidina à ropivacaína em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do período sem dor, embora os escores de dor em repouso e movimento, e a necessidade de analgésico de resgate, não tenham diferido.

Ropivacaína isolada ou associada à metadona ou à morfina, pela via epidural, em cadelas submetidas à ovário-histerectomia / Ropivacaine sole or associated to methadone or morphine, by epidural route, in bitches undergoing ovariohysterectomy

Objetivou-se avaliar os efeitos fisiológicos, sedativos e analgésicos da administração peridural de ropivacaína isolada ou associada à morfina ou à metadona. Para tal, 24 cadelas submetidas à ovário-histerectomia receberam acepromazina, e a anestesia foi induzida e mantida com propofol e isoflurano (FiO2 = 1,0), respectivamente. De acordo com o protocolo peridural, formaram-se três grupos de igual número: GR (ropivacaína - 2,0mg/kg); GRMETA (ropivacaína - 2,0mg/kg e metadona - 0,3mg/kg) e GRMORF (ropivacaína - 2,0mg/kg e morfina - 0,1mg/kg). Registraram-se os parâmetros fisiológicos intraoperatórios e os graus de sedação e analgesia pós-operatórios. No GR constataram-se maiores médias de pressões arteriais 30 minutos após a anestesia epidural em relação ao GRMETA (sistólica e média) e ao final do procedimento cirúrgico comparativamente ao GRMORF (sistólica, diastólica e média). Não foram observadas diferenças significativas entre os grupos relativamente à analgesia e ao grau de sedação pós-operatórios. A administração epidural de ropivacaína é segura e eficaz e proporciona boa analgesia, independentemente da sua associação com morfina ou metadona.(AU)

The aim of this study was to evaluate the physiological, sedative and analgesic effects of epidural administration of ropivacaine sole or associated to morphine or methadone. Twenty-four bitches were submitted to ovariohysterectomy and received acepromazine and after, propofol and isoflurane (FiO 2 = 1.0) for anesthesia induction and maintenance, respectively. Based on established epidural protocol (L7-S1), three groups were formed: GR (ropivacaine - 2.0mg/kg); GRMETA (ropivacaine - 2.0mg/kg and methadone - 0.3mg/kg) and GRMORF (ropivacaine - 2.0mg/kg and morphine - 0.1mg/kg). Intraoperative physiological parameters and degrees of postoperative sedation and analgesia were recorded. In the GR, the means of arterial pressures, 30 minutes after epidural anesthesia, were higher compared with GRMETA (systolic and mean) and, at the end of the clinical procedure, compared to GRMORF (systolic, diastolic and mean). Differences between groups were not observed for postoperative analgesia and degree of sedation. Epidural administration of ropivacaine is safe and effective and provides good analgesia regardless of its association with morphine or methadone.(AU)

Ropivacaine promotes apoptosis of hepatocellular carcinoma cells through damaging mitochondria and activating caspase-3 activity

BACKGROUND: Recent evidences indicated that some local anaesthetic agents played a role in inhibiting the proliferation of cancer cells; Whether ropivacaine is able to promote apoptosis of hepatocellular carcinoma (HCC) cells is still unclear. The aim of this study was to investigate the effect of ropivacaine on the apoptosis of HCC cells. METHODS: In the present study, we treated the HCC cell lines, Bel7402 and HLE with ropivacaine. MTT, DAPI stain, trypan blue exclusion dye assay, flow cytometry, electron microscopy, computational simulation, laser confocal microscope, Western blotting, and enzyme activity analysis of caspase-3 were applied to detect the growth and apoptosis of HCC cells and to explore the role mechanism of ropivacaine. RESULTS: Ropivacaine was able to inhibit proliferation and promote apoptosis of HCC cells in a dose- and time-dependent manner. Ropivacaine also has a trait to inhibit the migration of HCC cells; ropivacaine damaged the mitochondria of HCC cells. The results also indicated that ropivacaine was able to interact with caspase-3, promote cytoplasmic caspase-3 migration into the nucleus, stimulate cleavage of caspase-3 and PARP-1, caspase-9 proteins, inhibit the expression of Bcl-2, promote expression of Apaf-1 and mitochondria release cytochrome C, and activate the activity of caspase-3. CONCLUSIONS: Ropivacaine has a novel role in promoting apoptosis of HCC cells; The role mechanism of ropivacaine maybe involve in damaging the function of mitochondria and activating the caspase-3 signalling pathway in HCC cells. Our findings provide novel insights into the local anaesthetic agents in the therapy of HCC patients.

P38 MAPK inhibitor SB203580 attenuates the toxicity of ropivacaine on PC12 cells / 中南大学学报(医学版)

To investigate the effect of SB203580, a p38MAPK specific inhibitor, on ropivacaine-induced cytotoxicity in PC12 cells.
 Methods: PC12 cells were divided into three groups: the normal group (Group N), cells were cultured for 48 h; the ropivacaine group (Group R), cells were cultured with 15 mmol/L ropivacaine hydrochloride for 48 h; the ropivacaine+SB203580 group (Group R+S), cells were cultured with 15 mmol/L ropivacaine hydrochloride plus 10 μmol/L SB203580 for 48 h. The cell survival rates were detected by MTT assay. The protein levels of cleaved caspase-3, phosphor-p38 (p-p38) and cystolic cytochrome C (Cyt C) were detected by Western blotting.
 Results: Compared with the Group N, the number and survival rate of PC12 cells in the Group R and the Group R+S were significantly reduced (all P<0.05); the number and survival rate of PC12 cells in the Group R+S were significantly higher than those in the Group R (both P<0.05). Compared with the Group N, the levels of p-p38 and cleaved caspase-3, and the content of cytoplasmic Cyt C in the PC12 cells from the Group R and the Group R+S were significantly enhanced (all P<0.05); compared with the Group R, the levels of p-p38 and cleaved caspase-3, and the content of cytoplasmic Cyt C in the PC12 cells from the Group R+S were decreased (all P<0.05).
 Conclusion: The ropivacaine-induced cytotoxicity can be attenuated via inhibition of p38MAPK; which is related to decrease in Cyt C content and cleaved caspase-3 expression.

Efficacy of local infiltration of ropivacaine combined with multimodal analgesia with parecoxib for perioperative analgesia in patients undergoing pancreaticoduodenectomy / 南方医科大学学报

OBJECTIVE@#To explore the effect of local infiltration of ropivacaine combined with multimodal analgesia with parecoxib for perioperative pain management in patients undergoing pancreaticoduodenectomy.@*METHODS@#This randomized controlled trial was conducted among 98 patients undergoing pancreaticoduodenectomy in the Department of Biliary Surgery of West China Hospital between March, 2017 and August, 2018. The patients were randomized to receive perioperative analgesia with local infiltration anesthesia with ropivacaine combined with multimodal analgesia with parecoxib (experimental group, =50) or postoperative analgesia with dizosin (control group, =48). The regimens for intraoperative anesthesia and postoperative pain relief were identical in the two groups. The differences in NRS pain score, use of pain relief agents, the incidences of adverse reactions to analgesia and wound infection, and the time to first ambulation and first flatus passage after the operation were compared between the two groups.@*RESULTS@#At 12, 24 h, 48 h, 72 h and 7 days after the operation, the patients in the experimental group had significantly lower NRS scores ( < 0.05) than those in the control group. The rate of use of rescue analgesics was significantly lower in the experimental group than in the control group (32% 66.67%, < 0.05); the rate of tramadol hydrochloride use was also significantly lower in the experimental group ( < 0.05). Compared with those in the control group, the patients in the experimental group showed a significantly lower total incidence of adverse reactions (22% 54.17%, < 0.05) as well as a lower incidence of nausea and vomiting ( < 0.05), an earlier time of first ambulation and first flatus passage after the operation ( < 0.05), and a shorter postoperative hospital stay ( < 0.05).@*CONCLUSIONS@#In patients undergoing pancreaticoduodenectomy, local infiltration of ropivacaine combined with multimodal analgesia with ropivacaine can effectively relieve perioperative pain, reduce the use of relief analgesics, lower the incidence of adverse reactions, and promote the recovery after the surgery.

Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients - case series / Uso de ropivacaína em bloqueio do gânglio esfenopalatino via transnasal para cefaleia pós-punção dural em pacientes obstétricas - série de casos

Abstract Purpose Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. Clinical features We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48 h after dural puncture, with 4 mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48 h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. Conclusion The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24 h.

Resumo Justificativa e objetivo O bloqueio do gânglio esfenopalatino é amplamente aceito em dor crônica; porém, esse bloqueio tem sido subestimado no tratamento de cefaleia pós-punção dural. O bloqueio do gânglio não restaura a dinâmica normal do líquido cefalorraquidiano, mas reduz de modo eficaz os sintomas associados à hipotensão resultante. Quando aplicado corretamente, pode evitar a realização de tampão sanguíneo epidural. A abordagem transnasal é uma técnica simples e minimamente invasiva. Nos casos apresentados, tentamos realizar o bloqueio do gânglio e relatar sua eficácia e duração usando ropivacaína. Características clínicas Apresentamos quatro pacientes de obstetrícia com cefaleia pós-punção dural, após técnica epidural ou técnicas combinadas, com agulha Tuohy (18 G), que foram submetidas ao bloqueio do gânglio esfenopalatino de forma segura e bem-sucedida. Realizamos o bloqueio após 24 a 48 horas da punção dural, com 4 mL de ropivacaína a 0,75% em cada narina. Em três casos, a dor voltou em 1-48 horas, embora menos intensa. Em uma paciente, um segundo bloqueio foi realizado com alívio completo e sem recorrência. Nas outras duas pacientes, um tampão sanguíneo foi feito sem sucesso. Todas as pacientes estavam assintomáticas dentro de sete dias. Conclusão A duração média do efeito analgésico do bloqueio continua mal definida. Nos casos relatados, o bloqueio com ropivacaína foi uma técnica simples, segura e eficaz, com alívio imediato e prolongado da dor durante pelo menos 12-24 horas.