Analgesic Impact of a Popliteal Plexus Block to Standard Adductor Canal Block in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Randomized Blind Clinical Trial.

BACKGROUND: Damage to the anterior cruciate ligament (ACL) is crippling and often requires an arthroscopic outpatient surgery. Nevertheless, many patients experience severe pain during the first day after ACL reconstruction (ACLR). The adductor canal block (ACB) has yielded conflicting results for post-ACLR pain relief. This research investigated the effect of a supplemental popliteal plexus block on postoperative pain outcomes compared to a sole ACB. METHODS: Following a randomized design, 60 cases scheduled for knee arthroscopy with ACLR using an ipsilateral hamstring graft were separated into two categories. Subjects in group A (n = 30) received an ACB only, while subjects in group B (n = 30) received combined ACB and popliteal plexus block (PPB). RESULTS: We found significant differences between the two groups. The time of the first analgesic request (TFR) was later for the combined ACB and PPB (median 8 h) compared to the ACB only group (median 0.5 h). Morphine consumption was lower for patients who received combined ACB and PPB (median 12 mg) compared to ACB only (median 30 mg). The number of the requested doses was lower for the combined ACB and PPB group (median 3 doses) compared to the ACB only group (median 7 doses). CONCLUSIONS: The addition of PPB to ACB was associated with improved analgesia and a reduced need for opioid-based sedatives following ACLR with an ipsilateral hamstring graft (https://clinicaltrials.gov/ct2/show/NCT04020133).

Dexamethasone versus Hyaluronidase as an Adjuvant to Local Anesthetics in the Ultrasound-guided Hydrodissection of the Median Nerve for the Treatment of Carpal Tunnel Syndrome Patients.

BACKGROUND: Carpal tunnel syndrome (CTS) is one of the most common focal entrapment neuropathies. Although the exact etiology remains unclear, high-pressure-related intracarpal tunnel compression of the median nerve (MN), progressing ischemia, and mechanical strangulation are common mechanisms. The therapeutic managements for CTS depend on the disease severity, varying from a conservative treatment to surgical interventions. Conservative treatment is helpful for most of the patients with mild-to-moderate CTS. Hydrodissection is a minimally invasive procedure of injecting solutions into some anatomical spaces to facilitate dissection and adhesiolysis. Steroids as an anti-inflammatory drugs are used to treat chronic pain conditions. Hyaluronidase as an adhesolysis agent can also be used for epidural injections with local anesthetics (LAs) and steroids for control of chronic back pain. AIM OF THE STUDY: This study was carried out to compare the efficacy of hyaluronidase versus dexamethasone as adjuvants to the mixture of LAs in ultrasound (US)-guided hydrodissection of the median nerve in mild to moderate cases of carpal tunnel syndrome. SETTINGS AND DESIGN: This study was a prospective randomized controlled double-blinded clinical study. METHODS: 40 patients aged from 20 to 60 years old with clinical, electrophysiologic, and ultrasonographic evidence of mild to moderate CTS were included in this study. Each patient was assessed at the baseline (prior to injection) and at 1 week, 1 month, 3 months, and 6 months intervals after injection: (1) The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) which is a frequently used patient-based questionnaire for measurement of CTS. primary outcome. (2) Median motor and sensory nerve conduction studies (NCS) secondary outcome. (3) Median nerve ultrasonography. The ultrasound examination included measurement of the median nerve cross-sectional area (CSA) at the distal wrist crease (DWC). Also, the median nerve echogenicity, mobility, and vascularity at the DWC were assessed by US. Secondary outcome. All outcome assessments were assessed by single investigator who was blinded to the study details. All patients received US guided hydrodissection of the median nerve at the distal wrist crease. The selected patients were randomly allocated into 2 groups containing 20 patients each according to the study drugs; Group (D) received 5 mL (3 mL plain bupivacaine 0.5% and 2 mL (8 mg) dexamethasone), and Group (H) received 5 mL (3 mL plain bupivacaine 0.5% and 2 mL normal saline containing 300 international units (IU) hyaluronidase. Ultrasound-guided intracarpal injection using ultrasonography (Sono Scape A5; Shinzhen, China) with a 10-18-MHZ linear array transducer was performed by the same physician who was not aware of study groups, the MN was observed at the inlet of the carpal tunnel, 3 ml of solution was injected via the in-plane ulnar approach, to detach the MN from the transverse carpal ligament and an additional 2 ml was injected to separate the MN from underlying flexor tendons. All patients were observed for 30 minutes post injection for possible side effects before discharge. Normally distributed numerical data are presented as mean ± standard deviation, and differences between the groups were compared using the independent Student's t-test. Chi-square test was used for categorical data. Intragroup data at different follow up time points were evaluated using paired Student's t-test. All statistical tests were two-tailed, with P < 0.05 being considered statistically significant. RESULTS: The demographic data of the patients in both groups were statistically insignificant (P-value >0.05). In the pre-injection time, there were no statistically significant differences between both groups as regards BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score). The comparison between both groups showed that measured parameters as regards BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score) were significantly improved in group H compared with group D in the follow up periods at 1 week, 1 month, 3 months and 6 months post-injection (P-value <0.05). The comparison within each group showed that in group D, the measured parameters; BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score) were statistically significantly improved at 1 week, 1 month and 3 months follow up post-injection times but they were not significantly improved at 6 months post-injection time compared with the pre-injection data (P-value >0.05). While in group H, these measured parameters were statistically significantly improved in the all follow up post-injection times; at 1 week, 1 month, 3 months and even at 6 months periods compared with the baseline pre-injection data (P-value < 0.05). CONCLUSION: In this study, it was concluded that MN hydrodissction using hyaluronidase (as an adhesolysis agent) significantly improved patients with mild to moderate CTS compared to steroid (as an anti-inflammatory agents) hydrodissection of MN as regards BCTQ (SSS, FSS), electrophysiological studies (SNCV, DML), and sonographic data (CSA, echogenicity score, mobility score, and vascularity score) not only at 1 week, 1 month and 3 months follow up post-injection times but these parameters were also significantly improved at 6 months post-injection time in bupivacaine- hyaluronidase hydrodissection group compared to bupivacaine-steroid hydrodissection group.

Comparison between Position Change after Low-Dose Spinal Anesthesia and Higher dose with Sitting Position in Elderly Patients: Block Characteristics, Hemodynamic Changes, and Complications.

BACKGROUND: Large numbers of patients are presenting for surgeries with aging-related pre-existing conditions that make them at higher risks of adverse outcomes. Hemodynamic instability due to high sympathetic nerve block largely limits the use of conventional dose spinal anesthesia in high risk elderly patients. AIMS AND OBJECTIVES: We aimed to compare the hemodynamic stability and the block characteristics in low dose spinal anesthesia (5 mg) with immediate position change into supine position versus higher dose of spinal anesthesia (10 mg) with maintaining patient position in sitting position for 3 minutes after the block in elderly high risk population. SETTINGS AND DESIGN: This study was a prospective randomized controlled double-blinded clinical study. MATERIALS AND METHODS: This study was carried on 70 patients of American Society of Anesthesiologists physical status classes I, II, and III aged 50 years old and above, who were scheduled for elective knee and below knee orthopedic surgeries expected to last for 40-60 minutes under spinal anesthesia. Patients were randomly allocated into two groups: group (A) Sitting group n= 35 patients that received 10 mg hyperbaric bupivacaine 0.5% in 2 mL volume intrathecal at level lumbar (L4-5) in sitting position and remained in this position for 3 minutes before turning supine. And, group (B) Supine group n = 35 patients received 5 mg (low dose) intrathecal hyperbaric bupivacaine in 2 mL volume (1 mL hyperbaric bupivacaine 0.5% diluted with 1 ml sterile distilled water) at L4-5 in sitting position then turned supine immediately. The injection will be in the midline over 30 seconds by 25 gauge(G) Quincke needle. We measured the changes of mean arterial blood pressure, heart rate, O2 saturation and the incidence of hypotension and bradycardia intraoperatively as a primary outcome. Also, we measured the characteristics and the duration of the sensory and motor blocks, the duration required till return of bladder function and the satisfaction levels of both the patients and the surgeons as secondary outcomes. STATISTICAL ANALYSIS USED: Student's t-test and Chi-square test were used for analysis. RESULTS: As regards hemodynamics, mean arterial blood pressure and heart rate were significantly lower in group A compared to group B; P-value <0.05, during the intraoperative period, while MABP and HR were significantly decreasing in group A during the initial intraoperative period at 5 min, 10 min, 15 min, 20 min, 25 min, 30 min and 35 min, but in group B these parameters were statistically insignificant throughout the whole procedure P-value >0.05. As regards oxygen saturation, there were no significant differences between both groups or within the same group during the whole intraoperative period. Comparing sensory and motor blocks, sensory block was significantly higher and motor block was significantly dense in group A compared to group B during the first intraoperative period at 5 min, 10 min, 15 min, 20 min and 25 minutes. The recovery times from sensory and motor blocks were significantly longer in group A compared to group B (P-value <0.001). Also, the void recovery time was significantly longer in group A (129.29 ± 5.87 min) compared to group B (114.77 ± 8.24 min). In group B, patient satisfaction was significantly better (25 excellent/ 10 good) compared to group A (10 excellent/25 good). Also, surgeon satisfaction was statistically significantly better in group B (23 excellent/12 good) compared to group A (14 excellent/21 good). As regards side effects, in group A, 3 patients had to receive ephedrine due to significant reduction in MABP while no patients in group B had significant hypotension or bradycardia throughout the intra operative period. CONCLUSION: We concluded that the use of small dose of heavy bupivacaine 0.5% (5 mg) with immediate patient position changing to supine position provided good spinal block characteristics in elderly population without any hemodynamic side effects, also with better patient and surgeon satisfaction levels compared to higher doses of heavy bupivacaine (10 mg) even if we maintained patient position in the sitting position for 3 min after the block.

Comparative Study between the Efficacy of Fentanyl, Antihistamines, and Dexmedetomidine in Suppressing Photic Sneeze Reflex during Peribulbar Block.

BACKGROUND: The photic sneeze reflex (autosomal dominant) is a condition that causes sneezing in response to numerous stimuli, such as looking at bright lights or periocular (surrounding the eyeball) injection. Unexpected or sudden sneezing during injection can be a dangerous side effect in periocular injection, in which abrupt head movement may cause globe injury. AIMS: We intended to evaluate the efficacy of adding fentanyl, dexmedetomidine, and antihistamines on the incidence of the sneeze reflex associated with propofol sedation during periocular local anesthesia injections. SETTINGS AND DESIGN: Our study was a randomized, prospective, double-blinded and controlled clinical study. PATIENTS AND METHODS: This study was conducted in Ain Shams and Fayoum university hospitals at the ophthalmic surgery department. After obtaining approval from our universities ethical committee and written informed valid consents from the patients, 90 patients were included in this study. The study population included patients of both sex, ASA grade 1 and 2, in the age ranging from 18-65 years. Patients were scheduled for cataract extraction surgeries and received peribulbar block. Then patients were randomly divided into three groups (30 patients each) using a computer- generated table of random numbers. Patients were preoxygenated with supplemental oxygen by nasal cannula, all 90 patients received intravenous propofol 1mg.kg- 1 bolus for sedation and were randomized to receive adjunctive drug 2 to 4 minutes prior to propofol injection: 30 patients received intravenous fentanyl 1 µmg.kg-1 (Group F), 30 patients received dexmedetomidine 1µmg.kg-1 (Group D), and 30 patients received antihistamine (pheniramine 22.75 mg) (Group H). The same local anesthetic admixture, consisting of 5 mL 2% lidocaine with 90 IU hyaluronidase, combined with 5 mL 0.5% plain bupivacaine in a 10-mL syringe at room temperature was administered to all patients using peribulbar block technique. A masked observer (surgeon or anesthesia assistant) recorded whether the patient had a sneezing event. Continuous cardiorespiratory monitoring was performed intraoperatively. Intraoperative and postoperative medication side effects were recorded including bradycardia (HR <55 beats/min), hypotension (MAP <50 mmHg sustained for >10 min), oxygen desaturation (SpO2<90%), nausea, vomiting and prolonged sedation using Ramsay Sedation Score (RSS). STATISTICAL ANALYSIS USED: Student's t-test and Chi-square test were used for analysis. RESULTS: The demographic data of the three study groups revealed non-significant differences between the three study groups as regards age, sex distribution, and the duration of surgery. No patient was excluded after inclusion to the study. All patients were able to complete the entire study and their data were included in the final analysis. Five events of sneezing had occurred in 90 patients. Two in (D) group and three in (H) group with is no statistically significant difference between the three groups as regard sneezing. Bradycardia, hypotension and sedation had occurred significantly in group (D) compared to group (F) and group (D). No patient suffered from nausea, vomiting or oxygen desaturation in all studied groups. No statistically significant difference as regards patient satisfaction between the three studied groups. CONCLUSION: Fentanyl, dexmedetomidine and antihistamines with propofol sedation suppress photic sneeze reflex during peribulbar block.