The Effectiveness of Ultrasound-Guided, Continuous, Bilateral Erector Spinae Plane Block in Perioperative Pain Management of Patients Undergoing Colorectal Surgery: A Randomized, Controlled, Double Blind, Prospective Trial.

Open and laparoscopic colorectal surgeries, while essential in the management of various colorectal pathologies, are associated with significant postoperative pain. Effective perioperative pain management strategies remain an anesthesiologic challenge. The erector spinae plane block (ESPB), a novel peripheral nerve block, has gained attention for its potential in providing analgesia for a wide variety of surgeries. This study aimed to evaluate the effectiveness of continuous, bilateral ultrasound-guided ESPB in perioperative pain management of patients undergoing colectomy. This prospective, randomized, controlled, double-blind trial included 40 adult patients scheduled for elective open or laparoscopic colectomy. Patients undergoing open colectomy as well as patients undergoing laparoscopic colectomy were randomly allocated into two groups: the ESPB group (n = 20) and the control group (n = 20). All patients received preoperatively ultrasound-guided, bilateral ESPB with placement of catheters for continuous infusion. Patients in the ESPB group received 0.375% ropivacaine, while patients in the control group received sham blocks. All patients received standardized general anesthesia and multimodal postoperative analgesia. Pain scores, perioperative opioid consumption, and perioperative outcomes were assessed. Patients in the ESPB group required significantly less intraoperative (p < 0.001 for open colectomies, p = 0.002 for laparoscopic colectomies) and postoperative opioids (p < 0.001 for open colectomies, p = 0.002 for laparoscopic colectomies) and had higher quality of recovery scores on the third postoperative day (p = 0.002 for open and laparoscopic colectomies). Patients in the ESPB group did not exhibit lower postoperative pain scores compared to those in the control group (p > 0.05 at various time points), while patients in both groups reported comparable satisfaction scores with their perioperative pain management (p = 0.061 for open colectomies, and p = 0.078 in laparoscopic colectomies). No complications were reported. ESPB is a novel and effective strategy in reducing perioperative opioid consumption in patients undergoing colectomy. This technique, as part of a multimodal analgesic plan and enhanced recovery after surgery protocols, can be proven valuable in improving the comfort and satisfaction of patients undergoing colorectal surgery.

Dexmedetomidine as an adjuvant to scalp block in patients undergoing elective craniotomy: A prospective randomized controlled trial.

OBJECTIVE: Regional techniques minimize anesthetic requirements and their effects may be beneficial. There is a lack of consensus and evidence concerning alternative analgesia strategies for cranial neurosurgery. This study was designed to evaluate the effect of scalp block with or without dexmedetomidine combined with general anesthesia on hemodynamic stability, opioid consumption and postoperative pain in patients undergoing elective craniotomy. METHODS: One hundred five patients undergoing elective craniotomy for tumor dissection were randomly divided into three groups to receive scalp block as an adjuvant to general anesthesia: with either 40 ml ropivacaine 0.5 % (Group R), 40 ml ropivacaine 0.5 % plus dexmedetomidine 1 µg/kg (Group RD) or 40 ml saline as a placebo (Group C). After a standard induction sequence using propofol, fentanyl and a single dose of rocuronium, patients were intubated. Bilateral scalp block was given immediately after induction. Anesthesia was maintained with propofol and remifentanil infusion. Five minutes before head pinning scalp block was performed by blocking the supraorbital, supratrochlear, auriculotemporal, occipital, and postauricular branches of the greater auricular nerves. All patients were monitored with electrocardiogram, invasive blood pressure, pulse oximetry and BIS monitoring. Primary outcomes measures were overall hemodynamic variables during surgery and intravenous fentanyl and remifentanil consumption. Mean arterial pressure (MAP) and heart rate (HR) were recorded at seven time-points: scalp block (T1-baseline), pin fixation (T2), skin incision (T3), drilling (T4), dura matter incision (T5), dura matter closure (T6) and skin closure (T7). For all time points it was recorded the mean value after 3 consecutive measures with 5 min interval. Secondary outcome was postoperative pain intensity using visual analog scale 24 and 48 h after surgery. VAS scores, fentanyl and remifentanil were evaluated using Kruskal-Wallis test. MAP and HR were compared by One-Way repeated measures Anova (GLMM) using time as random efect and by One-Way Anova using time as fxed efect. RESULTS: Mean arterial pressure was significant lower at skin closure compared to baseline in group R (p < 0,001) and in group RD (p < 0,001). Patients in group RD showed significant lower heart rate at dura matter incision, dura matter closure and skin closure compared to baseline, pin fixation and skin incision time points (p < 0,001) and reported significantly less heart rate than group C (p < 0,001) and group R (p < 0,001) during dura matter incision, dura matter closure and skin closure time points. Patients in group RD receive significant lower fentanyl than group R (p < 0,01). The intraoperative consumption of remifentanil was significant higher in control group compared to group R (p < 0,01) and to group RD (p < 0,001). Additionally, remifentanil consumption was significant lower in group RD as compared to group R (p < 0,001). Postoperative pain had no statistically differences between the three groups at 24 h and 48 h after craniotomy (Preop VAS: p = 0,915, VAS 24: p = 0,284, VAS 48, p = 0,385). No adverse effects were noted. CONCLUSION: Our study indicated that addition of dexmedetomidine to scalp block with ropivacaine 0.5% provided significantly better perioperative hemodynamic stability during elective craniotomy. Moreover, scalp block with or without dexmedetomidine reduced fentanyl and remifentanil consumption, but it didn't significantly prolonged analgesia in patients undergoing elective craniotomy.

The Effect of Ultrasound-guided Bilateral Erector Spinae Plane Block With and Without Dexmedetomidine on Intraoperative and Postoperative Pain in Laparoscopic Cholecystectomies: A Randomized, Controlled, Double-blind, Prospective Trial.

BACKGROUND: Laparoscopic cholecystectomy is the most common surgical procedure performed in the Western world. While it is performed with minimally invasive procedures, patients often complain of moderate to severe postoperative pain, and the role of the anesthesiologist for its effective management remains crucial. Modern anesthesiology practices have embraced trunk blocks which can contribute to perioperative, multimodal analgesia. There is emerging literature about the favorable effect of erector spinae plane block in the reduction of pain after laparoscopic cholecystectomy. OBJECTIVE: The aim of this study was to explore the efficacy of preoperative bilateral erector spinae plane block when dexmedetomidine is added in the local anesthetic mixture in patients undergoing elective laparoscopic cholecystectomy. STUDY DESIGN: This study is a double-blind, randomized, controlled, prospective study. SETTING: Georgios Papanikolaou General Hospital of Thessaloniki, Greece. METHODS: After Local Ethics Committee approval (No: 1146/7.10.2019, October 2019) and in accordance with the principles outlined in the Declaration of Helsinki, the study was submitted to clinicaltrials.gov with reference number: NCT04587973. Sixty patients were randomized into 3 equal groups. Erector spinae plane block was performed in Group C with normal saline (N/S) 0.9%, in Group DR with ropivacaine 0.375% and dexmedetomidine 1 mcg/kg, and in Group R with ropivacaine 0.375%. The perioperative opioid consumption, pain intensity, time of first mobilization, hospitalization days, and satisfaction score of patients were recorded. Statistical analysis was performed with ANOVA, Kruskal-Wallis and Spearman test, as appropriate. RESULTS: The perioperative opioid consumption was significantly lower in Groups R and DR as compared to Group C (P < 0.001). The median numerical rating scale (NRS) scores of patients at all time points were statistically different between Groups C and DR, as well as between groups C and R. Satisfaction score was significantly higher in Group DR as compared to Group C (P < 0.001), and mobilization time was significantly shorter in group DR in comparison to Group C as well as in Group R as compared to Group C (P = 0.015 and P = 0.035, respectively). Intraoperative remifentanil consumption was lower in Group DR in comparison to Group R (P < 0.001). There was no difference in postoperative nausea and vomiting and duration of hospital stay of patients. LIMITATIONS: The limitation of the study is the small sample size of the patients recruited, which may be the reason why no statistically significant differences were found in postoperative morphine consumption and postoperative NRS scores between Groups R and DR and in postoperative nausea and vomiting among the 3 groups. CONCLUSION: Erector spinae plane block performed either with ropivacaine or with a combination of ropivacaine and dexmedetomidine is a novel and safe method, which was found to be more effective compared to standard analgesia protocols in patients undergoing laparoscopic cholecystectomy and thus, it can improve the quality of perioperative analgesia.

Metalloproteinase expression after desflurane preconditioning in hepatectomies: A randomized clinical trial.

BACKGROUND: Hepatectomy with inflow occlusion results in ischemia-reperfusion injury; however, pharmacological preconditioning can prevent such injury and optimize the postoperative recovery of hepatectomized patients. The normal inflammatory response after a hepatectomy involves increased expression of metalloproteinases, which may signal pathologic hepatic tissue reformation. AIM: To investigate the effect of desflurane preconditioning on these inflammatory indices in patients with inflow occlusion undergoing hepatectomy. METHODS: This is a single-center, prospective, randomized controlled trial conducted at the 4th Department of Surgery of the Medical School of Aristotle University of Thessaloniki, between August 2016 and December 2017. Forty-six patients were randomized to either the desflurane treatment group for pharmacological preconditioning (by replacement of propofol with desflurane, administered 30 min before induction of ischemia) or the control group for standard intravenous propofol. The primary endpoint of expression levels of matrix metalloproteinases and their inhibitors was determined preoperatively and at 30 min posthepatic reperfusion. The secondary endpoints of neutrophil infiltration, coagulation profile, activity of antithrombin III (AT III), protein C (PC), protein S and biochemical markers of liver function were determined for 5 d postoperatively and compared between the groups. RESULTS: The desflurane treatment group showed significantly increased levels of tissue inhibitor of metalloproteinases 1 and 2, significantly decreased levels of matrix metalloproteinases 2 and 9, decreased neutrophil infiltration, and less profound changes in the coagulation profile.  During the 5-d postoperative period, all patients showed significantly decreased activity of AT III, PC and protein S (vs baseline values, P < 0.05). The activity of AT III and PC differed significantly between the two groups from postoperative day 1 to postoperative day 5 (P < 0.05), showing a moderate drop in activity of AT III and PC in the desflurane treatment group and a dramatic drop in the control group. Compared to the control group, the desflurane treatment group also had significantly lower international normalized ratio values on all postoperative days (P < 0.005) and lower serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase values on postoperative days 2 and 3 (P < 0.05).   Total length of stay was significantly less in the desflurane group (P = 0.009). CONCLUSION: Desflurane preconditioning can lessen the inflammatory response related to ischemia-reperfusion injury and may shorten length of hospitalization.

Blood and fluid management during scoliosis surgery: a single-center retrospective analysis.

AIM: In the present retrospective study in scoliosis surgery, we hypothesized that application of a protocol for blood and fluid management, based on goal-directed fluid therapy, cell salvage and tranexamic acid, could lead to reduced allogeneic red blood cells transfusion. METHODS AND MATERIAL: Thirty-five patients, with American Society of Anesthesiologists physical status I/III, between 14 and 18 years scheduled for elective orthopedic surgery of scoliosis, with a planned intensive care unit admission, were enrolled in a retrospective observational study. Patients were divided in two groups. Patients in no-protocol group (Group noPro, n = 18) received a liberal intraoperative fluid therapy and patients in protocol group (Group Pro, n = 17) received fluid therapy managed according to a stroke volume variation-based protocol. The protocol included fluid therapy according to SVV monitor, permissive hypotension, tranexamic acid infusion, restrictive RBC trigger and use of perioperative cell savage. STATISTICAL ANALYSIS USED: Student's t test (2-tailed), Mann-Whitney test, Chi square test were used for statistical analysis of the data. RESULTS: There were no significant differences between the two groups in demographic data and clinical characteristics. Infused crystalloids (p = .003) and transfused allogeneic red blood cells (p = .015) were lesser in Group Pro compared to Group noPro. On the other hand, diuresis (p < .001) and vasopressors administration (p = .042) were higher in Group Pro than in Group noPro. CONCLUSION: The application of a protocol for blood and fluid management, based on goal-directed fluid therapy, cell salvage and tranexamic acid, was associated with less crystalloid fluid administration, less perioperative RBC transfusions and significantly better diuresis than patients in the no-protocol group in scoliosis surgery. REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT03814239.