Bilateral Greater Occipital Nerve Block; Distal Versus Proximal Approach for Postdural Puncture Headache: A Randomized Clinical Trial.

BACKGROUND: One of the common neuraxial anesthesia complications is postdural puncture headache (PDPH). Greater occipital nerve block (GONB) is a simple and safe maneuver with a faster onset than other treatment modalities. OBJECTIVES: Our work aims to compare the pain-relieving effect between distal and proximal ultrasound (US)-guided bilateral GONBs for PDPH. STUDY DESIGN: A randomized, double-blinded study. SETTING: Aswan University Hospital, Egypt. METHODS: The study included 50 patients of both genders, aged 20 to 60 years, who had PDPH with a sitting Numeric Rating Scale (NRS-11) >= 4. Patients were randomized into 2 equal groups. Group D received a US-guided distal bilateral GONB (at the superior nuchal line level). Group P received a US-guided proximal bilateral GONB (at the second cervical vertebra level). Three milliliters of isobaric bupivacaine 0.5% and 4 mg dexamethasone were injected in both blocks. RESULTS: There was a significant decrease in lying down and sitting NRS-11 at 10 minutes, 6, 12, 24, 36, and 48 hours after the intervention compared to before the intervention in both groups. Only sitting NRS-11 was significantly lower in group P than group D in all measurements after the intervention. Success rate (sitting NRS-11 < 4) at 24 hours was 60% in group D and 84% in group P, with an insignificant difference. The total 48-hour paracetamol and tramadol consumption was significantly lower in group P than in group D (P = 0.038 and 0.036, respectively). Transient cervicalgia occurred in 8% of each group. LIMITATIONS: The small number of cases to prove the secondary outcomes and the absence of a control group. CONCLUSIONS: US-guided proximal and distal GONBs were minimally invasive, simple, and effective ways to treat PDPH, with the superiority of proximal GONB in alleviating PDPH. KEY WORDS: Postdural puncture headache, distal, proximal, greater occipital nerve, block, ultrasound, pain-relieving, neuraxial anesthesia.

Effect of Dexmedetomidine, Dexamethasone, and Ondansetron on Postoperative Nausea and Vomiting in Children Undergoing Dental Rehabilitation: A Randomized Controlled Trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) are common unpleasant adverse effects after surgery. The incidence of PONV in pediatric patients is often twice as high as in adults. OBJECTIVES: This study aimed to evaluate the effects of dexmedetomidine, dexamethasone, and ondansetron for preventing PONV in children undergoing dental rehabilitation surgery. STUDY DESIGN: A prospective, randomized controlled clinical trial. SETTING: Sharurah Armed Forces Hospital, Ministry of Defense Medical Services, Saudi Arabia. METHODS: One hundred patients (6-12 years old) scheduled for dental rehabilitation were included. Patients were randomly allocated into 4 groups (25 each) to receive either 0.15 mg/kg dexamethasone (DEX), 0.05 mg/kg ondansetron (OND), 0.3 microgram/kg dexmedetomidine (DEXMED), or normal saline (control[CONT]) in DEX, OND, DEXMED or CONT groups, respectively, via infusion after induction of anesthesia. The primary outcome was a PONV incident in the first 24 hours. Secondary outcomes were: granisetron doses during 24 hours postoperative, Paediatric Anaesthesia Emergence Delirium (PAED) scale, Pediatric Objective Pain Scale (POPS) for 4 hours postoperatively, and complications in the first 24 hours. RESULTS: The reduction of PONV and the overall number of patients who developed PONV was statistically significant in the DEXMED group compared to the CONT group (P = 0.041). However, the DEXMED group was higher compared to the DEX and OND groups but not statistically significant. Granisetron requirements and doses were statistically significantly lower in the DEXMED group than in the CONT group. PAED and POPS scores were much better in the DEXMED group than in the other groups with a statistically significant difference in most of the time measurements. LIMITATION: Optimal dexmedetomidine dose for better effect on PONV without affecting hemodynamic stability requires more studies. CONCLUSION: Dexmedetomidine is effective in reducing PONV in children undergoing dental rehabilitation with better sedative and analgesic scores as compared to the control group.

Pediatric Postoperative Pain Control With Quadratus Lumborum Block and Dexamethasone in Two Routes With Bupivacaine: A Prospective Randomized Controlled Clinical Trial.

BACKGROUND: Ultrasound-guided Quadratus Lumborum block (QLB) is a regional analgesia approach that has been reported to provide effective post-operative pain relief for both abdominal and retroperitoneal surgery. Bupivacaine is the most often used and well documented local anesthetic medication in children. Dexamethasone is a systemic glucocorticoid that is often used to minimize postoperative nausea, vomiting, and pain to improve recovery quality after surgery. OBJECTIVES: To evaluate postoperative analgesia of QLB in pediatric patients undergoing renal surgeries by the addition of dexamethasone to bupivacaine compared to intravenous administration. STUDY DESIGN: A prospective, randomized, controlled clinical trial. SETTING: Pediatric surgery unit in a university hospital. METHODS: One hundred and five patients (6-12 years old) scheduled for renal surgeries were randomly allocated into 3 groups, with 35 patients in each group. Randomization was based on computer-generated codes. The groups were DEX1 (QLB with IV dexamethasone group), DEX2 (QLB dexamethasone group), and QLB CONTROL (QLB alone). The 1st time for rescue analgesia request, total morphine consumption, Pediatric Objective Pain Scale (POPS), and parents' satisfaction score were measured in 24 hours follow-up to evaluate postoperative pain control. RESULTS: The time to 1st rescue analgesics request (hours), total morphine consumption (mg), and the parents' satisfaction scores were much better in groups DEX1 and DEX2 as compared to group CONTROL with statistical significance. However, group DEX2 was better than DEX1 in the previous outcomes but without statistical significance. In respect, the pediatric objective pain scale was much lower with a significant difference in groups DEX1and DEX2 in comparison with group CONTROL up to 18 hours postoperatively. LIMITATIONS: Difficult to assess the block as all children were sedated, plus this was a unilateral surgical procedure with limited surgical incision, so the effect of QLB needed to be studied when there is a bilateral surgical procedure. CONCLUSIONS: Dexamethasone may be more effective when added to bupivacaine than when given systemically in analgesic effects without any impact on the other secondary pain-related outcomes. Dexamethasone as an adjuvant to bupivacaine has a marked hand on prolongation of the postoperative duration of analgesia, less request for rescue analgesia, and fewer side effects as compared to bupivacaine if used as a sole agent in QLB.

Pressure-controlled ventilation could decrease intraoperative blood loss and improve airway pressure measures during lumbar discectomy in the prone position: A comparison with volume-controlled ventilation mode.

BACKGROUND AND AIMS: Prone positioning may induce alterations of hemodynamic and airway pressure parameters that may affect intraoperative (IO) blood loss. Pressure-controlled ventilation (PCV) may modify these alterations. To observe the relation between ventilation mode and hemodynamic, airway pressure changes, and blood loss during lumbar discectomy performed in the prone position. MATERIAL AND METHODS: Volume-controlled ventilation (VCV) patients were using tidal volume (TV) of 8-10 ml/Kg, but for pressure-controlled ventilation (PCV) patients peak inspiratory pressure (PIP) was adjusted to provide the same TV according to ideal body weight. Respiratory and hemodynamic parameters were recorded in supine (T1), on turning to prone (T2), and on returning to the supine position (T3). Primary outcome included amount of IO blood loss; Secondary outcome included need for blood transfusion, IO hemodynamics, and airway pressure changes. RESULTS: IO blood loss and central venous pressure (CVP) were significantly higher with VCV than PCV patients. Heart rate and blood pressure were significantly reduced in the prone position with little impact of ventilation mode. Prone positioning resulted in significant increase of P-peak and non-significant decrease of P-mean pressure with VCV, while with PCV resulted in a significantly increased airway pressures. P-peak pressure was significantly lower with PCV in supine and prone positions than VCV. P-mean pressure was significantly lower in supine but significantly higher in the prone position with PCV than VCV. CONCLUSIONS: Prone positioning and VCV were associated with increased CVP and IO blood loss, while PCV could lessen these effects and significantly improve airway pressures.