Ultrasound-guided pericapsular nerve group (PENG) block for early analgesia in elderly patients with hip fractures: a single-center prospective randomized controlled study.

BACKGROUND: The aim of this study was to compare the efficacy of ultrasound-guided PENG (pericapsular nerve group) block and drug therapy with intravenous flurbiprofen for early analgesia in elderly patients with hip fractures after hospitalization. METHODS: This is a single-center, observer-blinded, prospective, randomized, controlled trial. A total of 41 elderly patients (aged 60 or older) with hip fractures were enrolled in the current study. Patients were randomly assigned to two groups: Group P (ultrasound-guided PENG block, 20 mL of 0.375% ropivacaine) and Group F (intravenous flurbiprofen 50 mg). The primary outcome measure was the dynamic (passive straight leg raising 15°) NRS (numerical rating scale 0 to 10) pain scores at different time points. The secondary outcomes were the static NRS scores at different time points, the number of rescue analgesia sessions, patient satisfaction, and the incidence of complications. RESULTS: Patients in the two groups had comparable baseline characteristics. The group P had lower dynamic and static NRS scores at 15 min, 30 min, 6 h, and 12 h after intervention (P<0.05) than the group F. The highest NRS pain scores in the group P were still lower than the NRS scores in the group F at 30 min-12 h (Group F: 5.57±1.54 vs. Group P: 3.00±1.12, P<0.001), and there was no significant difference between the two groups at 12-24 h (Group F: 6.35±1.79 vs. Group P: 5.90±1.83, P>0.05). The group P had higher satisfaction scores (Group P: 9 (9,9) vs. Group F: 8 (7,8), P<0.001). There was no statistically significant difference in the number of rescue analgesics at 0-12 h or 12-24 h or the incidence of complications between the groups. CONCLUSIONS: Compared with intravenous flurbiprofen, ultrasound-guided PENG block provides better early analgesic effects in elderly patients with hip fractures, and a PENG block is safe for elderly patients with hip fractures after hospitalization. Trial registration This study was registered in the Chinese Clinical Trial Testing Center (ID: ChiCTR2200062400).

The analgesic efficacy of pericapsular nerve group block in patients with intertrochanteric femur fracture: A randomized controlled trial.

BACKGROUND: The aim of this study is to evaluate analgesic efficacy of pericapsular nerve group (PENG) block in patients with intertrochanteric femur fracture (IFF). METHODS: This double-blinded randomized controlled trial in patients with IFF scheduled for proximal femoral nail antirotation (PFNA) between December 2020 and November 2021. The primary outcome was VAS scores during exercising at 6 h after surgery; secondary outcomes were pain during exercising and rest, intraoperative dose of remifentanil, cumulative dose of postoperative fentanyl, postoperative analgesia satisfaction scores, and ratio of quadriceps weakness. RESULTS: A total of 50 patients were randomly divided into PENG block group (n = 25) or fascia iliaca compartment block (FICB) group (n = 25). Exercising VAS scores at 6 h after surgery were significantly lower in PENG block group than that in FICB group (2 (2, 4) vs. 6 (4, 7), P < 0.001). The intraoperative dose of remifentanil and cumulative dose of postoperative fentanyl by patient-controlled intravenous analgesia within 24 h after surgery in PENG block group were significantly lower than in FICB group (both P < 0.001). Postoperative analgesia satisfaction scores in PENG block group were significantly higher than those in FICB group (P = 0.016). The ratio of quadriceps weakness at 6 h after surgery was significantly higher in FICB group than PENG block group (48% vs. 0%, P < 0.001). CONCLUSIONS: Compared to FICB, ultrasound-guided PENG block may provide better postoperative pain relief in patients with IFF, with less pronounced quadriceps weakness.

Ultrasound-guided, direct suprainguinal injection for fascia iliaca block for total hip arthroplasty: A retrospective study.

BACKGROUND: Peripheral regional block combined with general anesthesia might be a preferable anesthetic regimen for elderly patients undergoing total hip arthroplasty. AIM: To investigate whether ultrasound-guided, direct suprainguinal injection for fascia iliaca block accelerated recovery after general anesthesia and relieved postoperative pain after total hip arthroplasty. METHODS: Patients who underwent total hip arthroplasty under general anesthesia in 2015 or 2019 at The Second Affiliated Hospital of Xuzhou Medical University were retrospectively analyzed. The patients were grouped based on whether preoperative suprainguinal fascia iliaca block was performed or not. The time to tracheal extubation and time spent in the post-anesthesia care unit (PACU), intraoperative remifentanil dosage, fentanyl consumption in the PACU, postoperative cumulative fentanyl consumption within 48 h after operation, visual analogue scale at rest and during movement on the first and second days after surgery, and adverse reactions were compared. RESULTS: Thirty-one elderly patients who underwent total hip arthroplasty were included in the study (block group, n = 16; no-block group, n = 15). The visual analog scale scores at rest and during movement on the first and second days were significantly lower in the block group than in the no-block group (all P < 0.05). Compared with the no-block group, the intraoperative remifentanil dosage was lower, the time to tracheal extubation and the time spent in the PACU were shorter in the block group (all P < 0.01). Fentanyl consumption in the PACU and postoperative cumulative fentanyl consumption in 48 h after operation were lower in the block group (all P < 0.01). The incidence of dizziness was higher in the no-block group than in the block group (P = 0.037). CONCLUSION: Ultrasound-guided, direct suprainguinal injection for fascia iliaca block led to faster recovery after general anesthesia and early postoperative pain relief in elderly patients undergoing total hip arthroplasty.

MiR-22-3p suppresses sepsis-induced acute kidney injury by targeting PTEN.

BACKGROUND: Septic acute kidney injury is considered as a severe and frequent complication that occurs during sepsis. The present study was performed to understand the role of miR-22-3p and its underlying mechanism in sepsis-induced acute kidney injury. METHODS: Rats were injected with adenovirus carrying miR-22-3p or miR-NC in the caudal vein before cecal ligation. Meanwhile, HK-2 cells were transfected with the above adenovirus following LPS stimulation. We measured the markers of renal injury (blood urea nitrogen (BUN), serum creatinine (SCR)). Histological changes in kidney tissues were examined by hematoxylin and eosin (H&E), Masson staining, periodic acid Schiff staining and TUNEL staining. The levels of IL-1ß, IL-6, TNF-α and NO were determined by ELISA assay. Using TargetScan prediction and luciferase reporter assay, we predicted and validated the association between PTEN and miR-22-3p. RESULTS: Our data showed that miR-22-3p was significantly down-regulated in a rat model of sepsis-induced acute kidney injury, in vivo and LPS-induced sepsis model in HK-2 cells, in vitro. Overexpression of miR-22-3p remarkably suppressed the inflammatory response and apoptosis via down-regulating HMGB1, p-p65, TLR4 and pro-inflammatory factors (IL-1ß, IL-6, TNF-α and NO), both in vivo and in vitro. Moreover, PTEN was identified as a target of miR-22-3p. Furthermore, PTEN knockdown augmented, while overexpression reversed the suppressive role of miR-22-3p in LPS-induced inflammatory response. CONCLUSIONS: Our results showed that miR-22-3p induced protective role in sepsis-induced acute kidney injury may rely on the repression of PTEN.

An aorto-oesophageal fistula treated with endovascular aortic repair: the fate of untreated oesophageal lesion on endoscopic follow-up.

Oesophageal foreign body is an emergency situation. Once oesophageal perforation occurs, damage and subsequent infection involving surrounding tissue or organs may ensue. We present here a rare case of aorto-oesophageal fistula which was treated with challenges. An old lady with fishbone induced oesophageal perforation, aortic pseudoaneurysm and mediastinal haematoma was treated with great vessel stent-graft placed in aortic arch, and the fish bone was removed under endoscopy thereafter. During the early follow-up period, part of the graft stent was discovered in the oesophageal perforation with no haemorrhage. The patient is still in good condition during follow-up.

Low-dose butorphanol alleviates remifetanil-induced hyperalgesia in patients undergoing laparoscopic cholecystectomy.

OBJECTIVE: To evaluate the effects of low-dose butorphanol on hyperalgesia induced by high-dose remifetanil in patients undergoing laparoscopic cholecystectomy. DESIGN: Randomized double-blind clinical trial. SETTING: Intraoperative. PATIENTS: Seventy-five patients scheduled for laparoscopic cholecystectomy were enrolled. INTERVENTIONS: Randomly allocated into 3 groups, low dose of remifentanil (LR) group and high dose of remifentanil (HR) group received low (0.1µg kg(-1) min(-1)) or high (0.3µg kg(-1) min(-1)) doses of remifentanil, respectively, and butorphanol combined with remifentanil (BR) group received remifentanil (0.3µg kg(-1) min(-1)) and butorphanol (0.2µg/kg). MEASUREMENTS: The visual analog scale scores and cumulative consumption of fentanyl were recorded. MAIN RESULTS: Visual analog scale scores were significantly higher in the HR group than in the LR and BR groups (P<.001). The dose of intravenously given fentanyl was significantly higher in the HR group than in the LR and BR groups (P<.001). In addition, the HR group showed a significantly higher cumulative consumption of fentanyl during 5 to 8 hours after the operation (P<.001). CONCLUSIONS: A high dose of remifentanil induces postoperative hyperalgesia, which could be prevented by a continuous intravenous administration of a low dose of butorphanol.

[The changes of monocarboxylate transporter-2 in spinal cord horn in a rat model of chronic inflammatory pain].

OBJECTIVE: To investigate the changes in the levels of monocarboxylate transporter-2 in spinal cord horn in a rat model of chronic inflammatory pain. METHODS: Male SD rats weighting 180 - 220 g were randomly divided into two groups(n = 48): normal saline group (NS group), complete Freund's adjuvant group (CFA group). Rats were given injections of CFA 100 µl in left hind paw in group CFA, and an equal volume of saline was given injection in group NS. Mechanical withdraw threshold(MWT) and thermal withdraw latency(TWL) were measured at before injection(T0 and 3 h, 1 d, 3 d, 7 d, 14 d, and 21 d after injection(T1-7). Four rats were chosen from each group at T0-7 and sacrificed, and L4-5 segments of the spinal cord horn were removed for measurement of the expression of monocarboxylate transporter-2 by Western blot analysis. RESULTS: In CFA group, mechanical hyperalgesia and allodynia appeared on the 3 h after CFA injection, then until the day 14. The expression of monocarboxylate transporter-2 in the spinal dorsal horn of rats in CFA group was significantly higher than that in normal control group at T1-6(P <0.05). The protein level of monocarboxylate transporter-2 was apparently correlated with MWT and TWL(P <0.01 and P <0.05) in CFA group. CONCLUSION: The level of monocarboxylate transporter-2 in spinal dorsal horn is significantly increased in a rat model of chronic inflammatory pain and the change may involve in the formation and maintenance of central sensitization in spinal cord of chronic inflammatory uain.

Neuron-restrictive silencer factor in periaqueductal gray contributes to remifentanil-induced postoperative hyperalgesia via repression of the mu-opioid receptor.

BACKGROUND: The ultra-short-acting mu-opioid receptor (MOR) agonist remifentanil induces postoperative hyperalgesia both in preclinical and clinical research studies. However, the precise mechanisms remain unclear, although changes in opioid receptor expression might be a correlative feature. Neuron-restrictive silencer factor (NRSF) functions as a crucial regulator of MOR expression in specific neuronal cells. Using a mouse model of incisional postoperative pain, we assessed the expression of MOR and NRSF and investigated whether disruption of NRSF expression could prevent the postoperative nociceptive sensitization induced by surgical incision and subcutaneous infusion of remifentanil. METHODS: Paw withdrawal mechanical threshold (PWMT) and paw withdrawal thermal latency (PWTL) were independently used to assess mechanical allodynia and thermal hyperalgesia after surgery and cerebral ventricle injection of NRSF antisense oligonucleotide. Western blotting analyses were preformed to assess the expression levels of MOR and NRSF. RESULTS: NRSF expression levels were enhanced after intraoperative infusion of remifentanil, resulting in repression of MOR expression in the periaqueductal gray (PAG). NRSF blockade with an NRSF antisense oligonucleotide significantly enhanced the expression levels of MOR and alleviated mechanical allodynia and thermal hyperalgesia induced by intraoperative infusion of remifentanil. CONCLUSION: NRSF functions as a negative regulator of MOR in PAG and contributes to remifentanil-induced postoperative hyperalgesia. NRSF in PAG may be a potential target for this pain therapy.

A Randomized Study to Compare the Analgesic Efficacy of Ultrasound-Guided Block of Fascia Iliaca Compartment or Femoral Nerve After Patella Fracture Surgery.

The aim of this study was to compare the analgesic efficacy of the ultrasound-guided block of femoral nerve or fascia iliaca compartment in patients who underwent patella fracture surgery. Fifty patients were blinded and randomized into groups treated with continuous fascia iliaca compartment block (CFICB) (n = 25) or continuous femoral nerve block (CFNB) (n = 25) after patella fracture surgery. Analgesic effects of the two methods were assessed and compared. Patients from the two groups showed no significant difference in visible analog scales at rest and during movement, fentanyl consumption, nausea, and vomiting. The time of catheter insertion was significantly shorter in carrying out CFICB compared to that in performing CFNB (8.3 ± 1.4 vs 14.5 ± 3.0 min). Three of the 25 patients in CFNB group experienced dysesthesia of anterior of the thigh, a complication which was not observed in CFICB-treated patients. CFICB and CFNB were equally effective in relieving pain after the patella fracture surgery. However, compared to CFNB, CFICB was found to be safer and easier to perform.

[Changes of Mu-opioid receptor and neuron-restrictive silencer factor in periaquductal gray in mouse models of remifentanil-induced postoperative hyperalgesia].

OBJECTIVE: To determine the changes of Mu-opioid receptor (Mor) and neuron-restrictive silencer factor (NRSF) in periaquductal gray (PAG) in mouse models of remifentanil-induced postoperative hyperalgesia. METHODS: Thirty-two Kun-Ming mice were randomly divided into 4 groups (8 mice in each group): Group C (mice underwent a sham procedure and saline was infused subcutaneously over a period of 30 min), Group I (mice underwent a surgical incision and the same volume of saline), Group R (mice underwent a sham procedure and remifentanil was infused subcutaneously at the moment of surgical incision over a period of 30 min), and group IR (mice underwent a surgical incision and remifentanil). Paw withdrawal mechanical threshold (PWMT) and paw withdrawal thermal latency (PWTL) tests were performed 24 h before the operation and 2, 6, 24, and 48 h after the operation. The specimens were collected after behavioral testings at 48 h. The expressions of Mor and NRSF in mice's PAG neurons were determined by Western blot. RESULTS: Mechanical allodynia and thermal hyperalgesia developed in Group I, R and IR (P<0.01). Intraoperative infusion of remifentanil enhanced mechanical allodynia and thermal hyperalgesia in mice with planta incision (P<0.01). In Group R and Group IR, the expression of Mor was significantly lower (P<0.01) and NRSF was significantly higher (P<0.01) when compared with Group C and Group I. CONCLUSION: Intraoperative infusion of remifentanil induces postoperative hyperalgesia in mouse models, accompanied with decreased expressions of Mor and increased of NRSF level in PAG neurons, which may be involved in remifentanil induced hyperalgesia.

Continous epidural butorphanol decreases the incidence of intrathecal morphine-related pruritus after cesarean section: a randomized, double-blinded, placebo-controlled trial: Epidural butorphanol decreases the incidence of intrathecal morphine-related pruritus.

This randomized, double-blinded, placebo-controlled trial investigated the effect of continuous epidural butorphanol on intrathecal morphine-related pruritus in patients undergoing cesarean section. Eighty-three patients undergoing elective cesarean section under spinal anesthesia (1.5 mL of isobaric bupivacaine 0.5 % and 0.1 mg of preservative-free morphine) were enrolled in this study. Subjects were randomized to receive epidural butorphanol (n = 43) or normal saline combined bupivacaine (n = 40). In the study group, after the umbilical cord was clamped, patients were administered an epidural loading dose of 1 mg followed by a 48-h infusion of 0.004 % butorphanol with 0.1 % bupivacaine at a rate of 2 mL/h. In the normal saline group, saline was used for the loading dose and the infusion 0.1 % bupivacaine at a same rate. Postoperatively, a blinded observer recorded the incidence/severity of pruritus, visual analog pain scores and sedation level at 1, 3, 6, 9, 12, 24 and 48 h. The 48-h consumption of breakthrough analgesic (tramadol) was also noted. The primary outcome was the incidence of pruritus at 48 h. At 48 h, the incidence of pruritus was significantly lower in the butorphanol group (16.3 vs. 52.5 %; P < 0.001). Furthermore, compared with the normal saline group, the intensity of pruritus was also decreased with epidural butorphanol at 3, 6 and 9 h (all P ≤ 0.008). The pain scores were significantly lower at 12, 24 and 48 h (all P < 0.05) in the butorphanol groups. Patients only receiving bupivacaine required a higher cumulative dose of tramadol (37.5 ± 62.8 vs. 9.3 ± 36.6; P = 0.014). In patients undergoing elective cesarean section, continuous epidural butorphanol with bupivacaine decreases the incidence and severity of intrathecal morphine-related pruritus without adversely affecting the quality of postoperative analgesia.

Intravenous butorphanol administration reduces intrathecal morphine-induced pruritus after cesarean delivery: a randomized, double-blind, placebo-controlled study.

PURPOSE: Pruritus associated with intrathecal opioid administration is a common side effect. There is evidence that κ-opioid receptor agonists have antipruritic activity. Butorphanol has agonist actions at both κ-opioid and µ-opioid receptors. This study was designed to evaluate the antipruritic efficacy of butorphanol after intrathecal morphine administration in the setting of a randomized, double-blind study of parturients undergoing cesarean section. METHODS: Ninety-one women who received combined spinal-epidural anesthesia with 1.2 ml 0.5 % isobaric bupivacaine and 0.1 mg preservative-free morphine were included in this study. After delivery of the baby, the parturients were randomly allocated to two groups: butorphanol group (n = 46) and physiological saline group (n = 45). In the butorphanol group, parturients received an intravenous loading dose of 1 mg butorphanol followed by infusion of 0.2 mg/h butorphanol. The physiological saline group received an infusion of the same volume of physiological saline. The presence of pruritus, visual analog scores for pain, sedation scores, and adverse effects were recorded 1, 2, 4, 6, 8, 10, 12, and 24 h after intrathecal morphine administration. RESULTS: The incidence of pruritus at 24 h was significantly more frequent in the physiological saline group than in the butorphanol group (48.9 vs. 13.0 %, P < 0.001). The severity of pruritus was significantly greater in the saline group than in the butorphanol group 2, 4, 6, 8 and 10 h after intrathecal morphine injection (P = 0.004, 0.001, 0.002, and 0.003, respectively). The visual analog scale scores at 24 h were significantly lower in the butorphanol group than in physiological saline group (P < 0.001). The Ramsay sedation score in the butorphanol group was significantly higher than that in the physiological saline group after 1, 2, 4, 6, 8, 10, 12, and 24 h (P < 0.05). There were no significant differences between the two groups in nausea/vomiting and other adverse effects. CONCLUSION: Administration of intravenous butorphanol after delivery of the baby can reduce pruritus that has been induced by intrathecal morphine administration in cesarean delivery with combined spinal-epidural anesthesia.