Comparison of ultrasonography-guided lateral versus medial costoclavicular brachial plexus block in pediatric patients : A randomized clinical trial.

BACKGROUND AND AIMS: Costoclavicular brachial plexus block is gaining popularity due to its ease of application. Lateral and medial costoclavicular approaches have recently been defined. In the current study, we aimed to investigate the procedural execution of these approaches in the pediatric population. METHODS: In this study 55 children aged between 2 and 10 years were randomized to receive lateral (LC group) or medial (MC group) costoclavicular brachial plexus block after induction of general anesthesia for postoperative analgesia. All patients received bupivacaine (1 mg/kg, 0.25%) within the center of the cord cluster. The number of needle maneuvers was recorded as primary outcome. Block performing features (ideal ultrasound-guided brachial plexus cords visualization, needle pathway planning time, needle tip and shaft visualization difficulty, requirement of extra needle maneuver due to insufficient local anesthetic distribution, block performance time, total procedure difficulty) and postoperative pain-related data (block intensities, pain scores and analgesic requirements) were all compared as secondary outcomes. RESULTS: The LC group patients required less ultrasound visualization time (median 14 s, range 11-23 s vs. median 42 s, range 15-67 s, p < 0.001) and fewer needle maneuvers (median 1, range 1-2 vs. median 3, range 2-4, p < 0.001) compared to the MC group. Similarly, the median block performance duration was shorter (median 67 s, range 47-94 s vs. median 140s, 90-204 s, p < 0.01) and procedures were perceived as easier (median 4, range 4-5 vs. median 3, range 2-5, p = 0.04) in the LC group. All other parameters were comparable (p > 0.05). CONCLUSION: The lateral approach required less needle maneuvers than the medial approach. Both techniques represented a good safety profile with favorable analgesic features.

The Effect of Anaesthesia Management with Different Fresh Gas Flows on Cognitive Functions of Geriatric Patients: A Randomized Double-blind Study.

Objective: The present study aimed to compare the effects of two different fresh gas flows (FGFs) (0.5 L min-1 and 2 L min-1) applied during maintenance of anaesthesia on recovery from anaesthesia and early cognitive functions in geriatric patients. Methods: In this prospective, randomised, double-blind study, sixty patients were divided into two groups according to the amount of FGF. Minimal-flow anaesthesia (0.5 L min-1 FGF) was applied to group I and medium-flow anaesthesia (2 L min-1 FGF) was applied to group II during maintenance of anaesthesia. Following the termination of inhalation anaesthesia, recovery times were recorded. The evaluation of cognitive functions was performed using the Addenbrooke's Cognitive Examination (ACE-R). Results: There was no significant difference between the two groups in terms of demographic characteristics and recovery (P > 0.05). There was no significant difference between the two groups in terms of the preoperative day, the first postoperative day, and the third postoperative day; ACE-R scores (P > 0.05). In group II, on the third postoperative day ACE-R scores were found to be significantly lower than the preoperative ACE-R scores (P=0.04). In group II, third postoperative day ACE-R memory sub-scores (14.53 ± 3.34) were found to be significantly lower than preoperative ACE-R memory sub-scores (15.03 ± 3.57) (P=0.04). Conclusion: In geriatric patients, minimal-flow anaesthesia was not superior to medium-flow anaesthesia in terms of recovery properties and cognitive functions. Keeping in mind that hypoxaemia and changes in anaesthesia levels may occur with the reduction of FGF, both minimal- and medium-flow anaesthesia can be applied with appropriate monitoring without adverse effects on recovery and cognitive functions.

Comparison of hyperbaric oxygen and ozone treatment for ischemia/re-perfusion injury in an experimental testicular torsion model.

BACKGROUND: This study aims to compare the effects of medical ozone (MO) therapy and hyperbaric oxygen (HBO) therapy in an experimental testicular torsion model by measuring the oxidant and antioxidant markers and examining the histopathological tissue damage findings. METHODS: Thirty-two Wistar rats are used and are divided into four groups; (1) sham group (SG), (2) only ischemia/reperfusion (I/R) by testicular torsion, (3) HBO administered group, and (4) MO administered group. No torsion was conducted in the SG. In all other groups, rats underwent testicular torsion followed by detorsion to create an I/R model. After I/R, HBO was injected in the HBO group, and in the MO group, intraperitoneal ozone was applied. At the end of 1 week, testicular tissues were obtained for biochemical analyzes and histopathological examinations. Biochemically, malondialdehyde (MDA) levels were measured for oxidant activity, and superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) levels were measured for antioxidant activity. Furthermore, the testicles were evaluated histopathologically. RESULTS: Both HBO and MO have significantly decreased MDA levels, compared with sham and I/R groups, resulting in decreased oxidation effects. The antioxidant GSH-Px levels in the HBO and MO groups were significantly higher than in the sham and I/R groups. In addition, the antioxidant SOD levels in the HBO group were significantly higher than sham, I/R, and MO groups. Therefore, the antioxidant effect of HBO was observed to be superior to MO, specifically considering SOD levels. Histopathologically, there was no significant difference between the groups (p>0.05). CONCLUSION: The study may extrapolate that both HBO and MO are antioxidant agents that can be used in testicular torsion. HBO treatment might improve the cellular antioxidant capacity due to increased antioxidant marker levels more than MO therapy. However, further studies are needed with a larger sample size.

Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study.

BACKGROUND: Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients. METHODS: Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated. RESULTS: Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05). CONCLUSIONS: US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . TRIAL REGISTRATION: NCT04596787.

Comparison of ultrasound-guided supraclavicular and costoclavicular brachial plexus blocks in pediatric patients: a randomized clinical trial.

PURPOSE: Costoclavicular brachial plexus block has been described recently as a new technique in adults and pediatric patients. In this study, we aimed to compare the supraclavicular and costoclavicular approaches, which are claimed to be effective and practical in pediatric patients. METHODS: Sixty children were randomized to receive supraclavicular (SC group) or costoclavicular (CC group) brachial plexus blocks prior to surgical incision. Block performance times were recorded as the primary outcome. Procedural features (ideal brachial plexus cord visualization/needle pathway planning time, needle tip/shaft visualization difficulty, number of needle maneuvers, requirement of extra needle maneuvers due to insufficient local anesthetic distribution) and postoperative pain-related data (sensorimotor block intensities, Wong-Baker and FLACC pain scores and analgesic requirements) were also evaluated. To observe the tendency toward respiratory complications, ultrasonographic diaphragm movement amplitude (with M-mode) and diaphragm thickness (with B-mode) were measured postoperatively. RESULTS: A total of 56 patients were included. Block performance times [70(7-97) vs. 115(75-180) s] were significantly lower in the CC group (p < 0.01). The block success rates did not differ (p > 0.05). The incidence of hemidiaphragm paralysis was 44% in the SC group (p < 0.001), and inspiratory diaphragm thickness was significantly lower (p < 0.01). None of CC group patients experienced hemidiaphragm paralysis. All other parameters were comparable (p > 0.05). CONCLUSIONS: Although costoclavicular block did not show superiority in pain management, the block performance was perceived as more practical than supraclavicular block. We believe that costoclavicular brachial plexus block stands as a good option in upper extremity surgeries with the advantages of shorter block performance time and reduced ipsilateral hemidiaphragm paralysis risk in pediatric patients.

Effects of ultrasound guided caudal epidural and transversus abdominis plane block on postoperative analgesia in pediatric inguinal hernia repair surgeries.

INTRODUCTION: Ultrasound guided caudal epidural block (CEB) and transversus abdominis plane block (TAPB) are two techniques which are used for pain management after inguinal hernia surgeries (IHR). CEB is accepted as gold standard for lower abdominal surgeries while TAPB is more popular. OBJECTIVE: It is aimed to compare ultrasound guided CEB and TAPB for postoperative pain scores, additional analgesic requirement and chronic pain development in pediatric bilateral open IHR. STUDY DESIGN: Seventy patients aged 1-7 years undergoing bilateral open IHR were included in this prospective, randomized, double-blinded study. Patients were randomized into group T (Bilateral TAPB) and group C (CEB). Postoperative FLACC (Face, Legs, Activity, Cry, Consolability) scores were evaluated for pain density. Additional analgesic requirement, length of hospital stay was also recorded. Chronic pain is evaluated within a subgroup by using "revised Bieri faces pain scale" in the postoperative second month. RESULTS: Postoperative 15th, 30th, 45th min, first, second hour FLACC scores were similar in both groups (P > 0.05). In group C, FLACC scores at postoperative sixth and 24th were significantly higher than group T (1 (0-5) vs 0 (0-2); 1 (0-3) vs 0 (0-2), respectively; P < 0.001). Additional analgesic requirement in the postoperative 24 h was found to be statistically higher in Group C (56.7%) than in Group T (20%) (P < 0.01). Chronic pain development did not differ between the groups (P > 0.05). Length of hospital stay was found to be shorter in patients in Group T compared to patients in Group C [10 (5-14) vs 16 (5-18) hours, respectively; P < 0.01)]. DISCUSSION: Our results exhibited that TAPB and CEB for bilateral IHR have similar early analgesic efficacy in children. However; CEB patients experienced higher FLACC scores at the postoperative sixth and 24th hours, and the need for additional analgesics was higher and the length of hospital stay was longer comparing to TAPB. Of note, chronic pain was not observed in any of our subgroup patients (n = 21) who are older than four years. CONCLUSION: For bilateral IHR, US-guided CEB and TAPB have similar analgesic efficacy in the first six hours, postoperatively, However, TAPB appears to be slightly superior than CEB in terms of subacute pain and length of stay which is still not clinically distinctive.

The Effects of Lateral 45° Head-Down Position and Carbon Dioxide Pneumoperitoneum on the Optic Nerve Sheath Diameter in Patients Undergoing Laparoscopic Transperitoneal Nephrectomies: A Prospective Observational Study.

Background: The aim of this study is to assess the extent of the increased intracranial pressure resulting from lateral decubitus and 45° downward positioning using sonographic optic nerve sheath diameter (ONSD) in patients undergoing laparoscopic transperitoneal nephrectomy. In addition, we evaluated the effect of the carbon dioxide pneumoperitoneum (CO2PP) on ONSD. Materials and Methods: Twenty-four adults were enrolled in this prospective observational study. Longitudinal and transverse ONSDs were measured for each eye by ocular ultrasonography. The values were noted in supine position (T0), 20 minutes after induction of anesthesia (T1), after insufflation of the abdomen in lateral 45° head-down position (T2), at 30-minute intervals during surgery (T3-T4-T5), during lateral 45° head-down position after CO2 exsufflation (T6), before awakening while supine (T7), and at postoperative 24th hour (T8). Hemodynamic and respiratory parameters were investigated at the measurement time points. Results: Average ONSD values for the lower eye was T0 = 4.27 ± 0.4 mm, T1 = 4.56 ± 0.6 mm, T2 = 4.84 ± 0.6 mm, T3 = 4.91 ± 0.4 mm, T4 = 4.99 ± 0.5 mm, T5 = 4.97 ± 0.5 mm T6 = 4.96 ± 0.5 mm, T7 = 4.76 ± 0.4 mm, T8 = 4.36 ± 0.5 mm and for the upper eye was T0 = 4.24 ± 0.4 mm, T1 = 4.39 ± 0.5 mm, T2 = 4.54 ± 0.5 mm, T3 = 4.60 ± 0.4 mm, T4 = 4.66 ± 0.4 mm, T5 = 4.72 ± 0.7 mm, T6 = 4.68 ± 0.4 mm, T7 = 4.52 ± 0.4 mm, T8 = 4.30 ± 0.4 mm (P < .001). Conclusion: In our study, we observed a significant increase in ONSD within minutes after the patient was placed in a head-down position. We also observed that the difference increased more with CO2PP and was proportional to the length of the surgery. We found that it regressed to initial levels at the postoperative 24th hour. Clinicaltrials.gov: NCT05185908.

Comparison of epidural analgesia combined with general anesthesia and general anesthesia for postoperative cognitive dysfunction in elderly patients.

BACKGROUND: Cognitive dysfunction in the early postoperative course is common for the elderly population. Anesthetic management may affect postoperative cognitive decline. Effective analgesia, early recovery and modulation of the stress response are advantages of neuraxial blocks. This study aims to compare the effects of general anesthesia and the combination of general anesthesia with epidural analgesia for postoperative cognitive dysfunction (POCD). We hypothesized that neuraxial block combined with general anesthesia (GA) would have a favorable influence on POCD prevention. METHODS: Patients above 60 years undergoing non-cardiac surgery were included in this randomized, prospective study and randomized into two groups. Patients in the first group (GI) were treated under GA, whereas in the second group (GII), epidural analgesia was combined with GA. Patients' cognitive function was assessed before and one week after surgery using a neuropsychological test battery. POCD was defined as a drop of one standard deviation from baseline on two or more tests. RESULTS: A total of 116 patients were allocated for the final analysis. Demographic and operative data were similar between groups, except maximum pain scores, which were significantly higher in GI than GII (4.9±2.8 vs. 1.7±1.7; p<0.001, respectively). The incidence of POCD was comparable between groups (26% in GI and 24% in GII). Memory performance, visuospatial functions, and language skills tests were significantly higher in GII compared to GI. CONCLUSION: General anesthesia and epidural analgesia combined with general anesthesia resulted in similar POCD in elderly patients undergoing abdominal surgery. However, in combined anesthesia group memory, language skills and visuospatial functions appeared to be better preserved. Effective pain control might contribute to preventing cognitive decline in some domains.

Effects of Different Volatile Anesthetics on Cytokine and Chemokine Production After Ischemia-Reperfusion Injury in Patients Undergoing Living-Donor Kidney Transplant.

OBJECTIVES: Renal transplant is the treatment of choice for patients with end-stage renal disease. Ischemiareperfusion damage is a major cause of early renal dysfunction during the perioperative period. Ischemic hypoxic damage increases local inflammation, leading to secretion of cytokines and chemokines. Anesthetic conditioning is a widely described strategy to attenuate ischemia-reperfusion injury. Here, we compared the effects of desflurane and sevoflurane on serum proinflammatory cytokines and urine chemokines in living-donor kidney transplant recipients. MATERIALS AND METHODS: Eighty donor-recipient couples were included in this randomized study. Anesthesia maintenance was provided by desflurane or sevoflurane. Patient demographic characteristics, immunologic data, clinical data, and hemodynamic parameters were recorded. Tumor necrosis factor α, interleukins 2 and 8, chemokines 9 and 10, and serum creatinine levels were studied from pretransplant, posttransplant days 1 and 7, and posttransplant months 1 and 3 sample results. Estimated glomerular filtration rates were calculated. Acute rejection episodes and graft loss within 6 months posttransplant were recorded. RESULTS: Seventy donor-recipient couples completed the study. There were no significant differences in demographic, immunologic, and clinical data between desflurane and sevoflurane groups (P > .05). Tumor necrosis factor α, interleukin 2, chemokine 9, and chemokine 10 levels were similar preoperatively and on postoperative days 1 and 7 and months 1 and 3 (P > .05). Serum interleukin 8 levels were significantly higher in patients who received sevoflurane on postoperative days 1 (P = .045) and 7 (P = .037). No significant differences were detected in serum creatinine and estimated glomerular filtration rate between groups (P > .05). No graft loss occurred within 6 months posttransplant. CONCLUSIONS: Although sevoflurane seemed to produce higher interleukin 8 levels posttransplant, both desflurane and sevoflurane had similar effects on posttransplant kidney function. We suggest that both agents have protective effects on ischemic-reperfusion damage in living-donor kidney transplant recipients.

Neutrophil Gelatinase-associated Lipocalin Significantly Correlates with Ischemic Damage in Patients Undergoing Laparoscopic Partial Nephrectomy

Background: Laparoscopic partial nephrectomy, which minimizes renal function loss due to its nephron sparing nature, has become a standard technique among many experienced centers worldwide for surgical treatment of localized kidney tumors. Although partial nephrectomy will remain the gold standard, we need to improve perioperative management and surgical method to prevent postoperative acute kidney injury. Aims: To demonstrate the frequency of the development of postoperative acute kidney injury following laparoscopic partial nephrectomy in patients with healthy contralateral kidney and determine the early predictive effects of serum neutrophil gelatinase-associated lipocalin on ischemia-reperfusion injury and its association with warm ischemia time. Study Design: Cross-sectional study. Methods: Eighty patients were included. We analyzed tumor size, operating time, duration of anesthesia, and warm ischemia time. Serum samples were obtained for measurement of serum creatinine, estimated glomerular filtration rate, and neutrophil gelatinase-associated lipocalin level preoperatively, at the postoperative 2nd hour, and on postoperative days 1 and 2. We used receiver operating characteristic curve for determining the cut-off point of neutrophil gelatinase-associated lipocalin to detect postoperative acute kidney injury. Correlation analysis was performed using Spearman's test. Results: Twenty-seven patients developed acute kidney injury on postoperative day 2, and the neutrophil gelatinase-associated lipocalin level increased significantly at the postoperative 2nd hour in the acute kidney injury group (p=0.048). For a cut-off of 129.375 ng/mL neutrophil gelatinase-associated lipocalin, the test showed 70.0% sensitivity and 68.3% specificity for the detection of acute kidney injury at the postoperative 2nd hour. For a cut-off of 184.300 ng/mL neutrophil gelatinase-associated lipocalin, the test exhibited 73.3% sensitivity and 63.3% specificity for the detection of acute kidney injury on postoperative day 1. A significant correlation was found between warm ischemia time and neutrophil gelatinase-associated lipocalin level at the postoperative 2nd hour (r=0.398, p=0.003). The creatinine values were significantly higher and the estimated glomerular filtration rates were significantly lower on postoperative days 1 and 2 in the acute kidney injury group compared with those in the non-acute kidney injury group (p<0.001). Conclusion: The neutrophil gelatinase-associated lipocalin may be used as an alternative biomarker to serum creatinine in differentiation of ischemic damage in patients undergoing laparoscopic partial nephrectomy.

Use of ultrasound-guided supraclavicular brachial plexus block as an anesthesia technique in a patient with neurofibromatosis type 1: A case report.

Neurofibromatosis type 1 is an autosomal dominant condition characterized by cutaneous and/or plexiform neurofibromas and hyperpigmented café-au-lait spots. It affects multiple endocrine and visceral organs and can be associated with several difficulties such as potential airway (ventilation/intubation) problems, abnormal spinal anatomy, and peripheral neurofibromas. Therefore, anesthesia technique selection becomes more of an issue in terms of avoiding complications and decreasing morbidity and mortality. In the present case, we describe the use of ultrasound and the successful performance of supraclavicular brachial plexus block for surgery on the arm and forearm in a patient with neurofibromatosis type 1.

Serum and Urinary Levels of Tumor Necrosis Factor-Alpha in Renal Transplant Patients.

OBJECTIVES: Allograft rejection is an important cause of early and long-term graft loss in kidney transplant recipients. Tumor necrosis factor-alpha promotes T-cell activation, the key reaction leading to allograft rejection. Here, we investigated whether serum and urinary tumor necrosis factor-alpha levels can predict allograft rejection. MATERIALS AND METHODS: This study included 65 living related-donor renal transplant recipients with mean follow-up of 26 ± 9 months. Serum and urinary tumor necrosis factor-alpha levels were measured at pretransplant and at posttransplant time points (days 1 and 7 and months 3 and 6); serum creatinine levels were also monitored during posttransplant follow-up. Standard enzyme-linked immunoabsorbent assay was used to detect tumor necrosis factor-alpha levels. Clinical variables were monitored. RESULTS: Nine of 65 patients (13.8%) had biopsy-proven rejection during follow-up. Preoperative serum and urinary tumor necrosis factor-alpha levels were not significantly different when we compared patients with and without rejection. Serum tumor necrosis factor-alpha levels (in pg/mL) were significantly higher in the allograft rejection versus nonrejection group at day 7 (11.5 ± 4.7 vs 15.4 ± 5.8; P = .029) and month 1 (11.1 ± 4.8 vs 17.8 ± 10.9; P =.003). Urinary tumor necrosis factor-alpha levels (in pg/mL) were also elevated in the allograft rejection versus the nonrejection group at days 1 (10.2 ± 2.5 vs 14.1 ± 6.8; P = .002) and 7 (9.8 ± 2.2 vs 14.5 ± 2.7; P < .001) and at months 1 (8.0 ± 1.7 vs 11.8 ± 2.4; P < .001), 3 (7.7 ± 1.6 vs 9.6 ± 1.7; P = .002), and 6 (7.4 ± 1.6 vs 8.9 ± 0.9; P = .005). CONCLUSIONS: Our preliminary findings suggest that tumor necrosis factor-alpha has a role in diagnosing renal transplant rejection. Serum and urinary tumor necrosis factor-alpha levels may be a possible predictor for allograft rejection.

Can surgical approach affect postopertive analgesic requirements following laparoscopic nephrectomy: transperitoneal versus retroperitoneal? A prospective clinical study / ¿Puede el abordaje quirúrgico afectar a la necesidad de analgésicos postoperatorios después de nefrectomía laparoscópica?: Nefrectomía Transperitoneal versus Retroperitoneal. Un estudio clínico prospectivo

OBJECTIVES: We performed this prospective clinical study to compare the postoperative recovery profile of our patients after transperitoneal (Group T) and retroperitoneal (Group R) laparoscopic nephrectomy approaches. Our primary hypothesis was that epidural analgesic consumption in Group R would be higher at the end of the first postoperative day. Methodos: Forty-four patients scheduled for elective transperitoneal or retroperitoneal laparoscopic nephrectomies were enrolled. All patients in both groups received epidural catheter and general anesthesia induction. At the end of the operation, patients were given 10 ml 0.25% bupivacaine through epidural catheters and extubated. Postoperatively, patients started to receive a continuous infusion of 0.1% bupivacaine and 1μg/ml fentanyl 5ml/h with patient- controlled boluses of an additional 4ml through a patient controlled epidural analgesia (PCEA) device. They were prescribed IV tramadol 1mg/kg as a rescue analgesic (VAS≥4). Total analgesic consumption from PCEA devices and VAS scores during the first 24 postoperative hours were recorded as well as number of patients who required analgesic rescue.RESULTS: Forty patients completed the study, 20 in each group. Total epidural analgesic consumption during the first 12 hours were significantly higher in Group R (p < 0.05). Basal, postoperative 30 min, 2, 6 hours VASrest, VASmobilization and 12 h VASmobilization scores, and number of patients who required rescue analgesic at 0, 30 min in Group R were significantly higher than Group T (p < 0.05).CONCLUSION: Retroperitoneal laparoscopic nephrectomy was found to be more painful and patients in this group required more epidural and analgesic rescue during the first 12 postoperative hours. ClinicalStudys.gov: (NCT02622893)

OBJETIVO: Realizamos este estudio clínico prospectivo para comparar el perfil de recuperación postoperatorio de nuestros pacientes después de nefrectomía laparoscópica con abordajes retroperitoneal (Grupo R) y transperitoneal (Grupo T). Nuestra hipótesis principal fue que el consumo de analgesia epidural en el grupo R era superior al final del primer día postoperatorio. MÉTODOS: Cuarenta y cuatro pacientes programados para nefrectomía laparoscópica electiva, transperitoneal o retroperitoneal, fueron incluídos. Todos los pacientes en ambos grupos recibieron catéter epidural y la inducción de la anestesia general. Al final de la cirugía, los pacientes recibieron 10 ml de bupivacaína 0,25% a través de los catéteres epidurales y fueron extubados. Postoperatoriamente, los pacientes comenzaron a recibir una infusión continua de 0,1% de bupivacaína y fentanilo de 1μg/ml 5ml/h con bolos adicionales de 4 ml controlados por el paciente a través de un dispositivo de analgesia epidural controlado por el paciente (PCEA). Se prescribió tramadol 1mg/kg IV como analgésico de rescate (EVA≥4). Se registraron el consumo total de analgésicos de los dispositivos PCEA y las puntuaciones EVA durante primeras 24 horas del postoperatorio, al igual que el número de pacientes que requirieron analgesia de rescate. RESULTADOS: Cuarenta pacientes completaron el estudio, 20 en cada grupo. El consumo total de analgésicos epidurales durante las primeras 12 horas fue significativamente mayor en el grupo R (p < 0,05). Las EVA en reposo basales, a los 30 min, 2 y 6 horas, y las EVA en movilización a 12 h y el número de pacientes que requirieron analgesia de rescate en tiempo 0 y 30 min en el grupo R fueron significativamente mayores que el Grupo T (p < 0,05). CONCLUSIÓN: La nefrectomía laparoscópica retroperitoneal fue más dolorosa y los pacientes de este grupo requirieron más analgesia epidural y rescates durante las primeras 12 horas del postoperatorio. ClinicalStudys.gov: (NCT02622893)

Can surgical approach affect postoperative analgesic requirements following laparoscopic nephrectomy: Transperitoneal versus retroperitoneal? A prospective clinical study.

OBJECTIVES: We performed this prospective clinical study to compare the postoperative recovery profile of our patients after transperitoneal (Group T) and retroperitoneal (Group R) laparoscopic nephrectomy approaches. Our primary hypothesis was that epidural analgesic consumption in Group R would be higher at the end of the first postoperative day. METHODS: Forty-four patients scheduled for elective transperitoneal or retroperitoneal laparoscopic nephrectomies were enrolled. All patients in both groups received epidural catheter and general anesthesia induction. At the end of the operation, patients were given 10 ml 0.25% bupivacaine through epidural catheters and extubated. Postoperatively, patients started to receive a continuous infusion of 0.1% bupivacaine and 1µg/ml fentanyl 5ml/h with patient-controlled boluses of an additional 4ml through a patient controlled epidural analgesia (PCEA) device. They were prescribed IV tramadol 1mg/kg as a rescue analgesic VAS≥4). Total analgesic consumption from PCEA devices and VAS scores during the first 24 postoperative hours were recorded as well as number of patients who required analgesic rescue. RESULTS: Forty patients completed the study, 20 in each group. Total epidural analgesic consumption during the first 12 hours were significantly higher in Group R (p<0.05). Basal, postoperative 30 min, 2, 6 hours VASrest, VASmobilization and 12 h VASmobilization scores, and number of patients who required rescue analgesic at 0, 30 min in Group R were significantly higher than Group T (p<0.05). CONCLUSION: Retroperitoneal laparoscopic nephrectomy was found to be more painful and patients in this group required more epidural and analgesic rescue during the first 12 postoperative hours. ClinicalStudys.gov: (NCT02622893).

Ultrasound-Guided Bilateral Thoracic Paravertebral Blocks as an Adjunct to General Anesthesia in Patients Undergoing Reduction Mammaplasty: A Historical Cohort Study.

BACKGROUND: This study investigates whether ultrasound-guided thoracic paravertebral blocks would improve postoperative analgesia in patients undergoing bilateral reduction mammaplasty. METHODS: After obtaining ethics committee approval, data of 70 patients who underwent bilateral reduction mammaplasty were reviewed. Sixty-four patients' data were evaluable; 30 were in the general anesthesia group and 34 were in the thoracic paravertebral block group. Data such as time to first pain, intraoperative fentanyl requirement, postoperative numeric rating scale scores, number of patients who required tramadol in the postoperative care unit, and rescue analgesic consumption through the first 2 postoperative days were analyzed. RESULTS: Time to first pain was 311 minutes (range, 0 to 1605 minutes) and 20 minutes (range, 0 to 120 minutes) in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Fentanyl requirement was 52.94 ± 11.94 µg and 115 ± 29.79 µg in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Numeric rating scale scores were lower in the thoracic paravertebral block group through the first 2 postoperative hours (p < 0.001), and only two of 34 patients required tramadol in the postoperative care unit (p < 0.001). On postoperative day 1, both metamizole sodium (p < 0.001) and paracetamol (p = 0.018), and on day 2, only metamizole sodium (p < 0.001) consumption was lower in the thoracic paravertebral block group. CONCLUSION: Adding ultrasound-guided thoracic paravertebral blocks to general anesthesia postponed time to first pain and reduced analgesic consumption in patients undergoing bilateral reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.