Case Report: Erector Spinae Block in Perforated Viscus.

Background: Erector spinae plane block (ESPB) a new block described for post-operative analgesia. Since 2016 the block has become a common practice in many institutions globally. Evidence has shown that ESPB is superior to truncal and abdominal wall blocks for many thoracic and abdominal surgeries. Case Presentation: A 29-year-old male, ASA (American Society of Anesthesiologists) IIE patient presented with acute appendicitis. Patient was scheduled to undergo Laparoscopic Appendicectomy under general anesthesia (GA) with ESPB for post op analgesia. In the operating room after induction of GA patient received an ultrasound (US) guided bilateral ESPB at T10 level of the spinal cord with 20 mls of 0.25% levobupivacaine on each side. Intraoperatively the appendix was found to be normal and there was an incidental finding of perforated superior/first part of duodenum (D1). The duodenum was repaired. Patient remained hemodynamically stable intraoperatively. No intraoperative morphine was required. After uneventful extubation, the patient was transferred to post-operative anesthesia care unit (PACU). Patient reported pain score of zero on a 11-point numerical rating scale (NRS) in PACU. No morphine was required in the next 24 hours on the ward either. Conclusion: ESPB can provide opioid free analgesia for laparoscopic repair of perforated duodenal ulcer both intra and postoperatively.

Determination of the minimum initial intrathecal dose of isobaric 0.5% bupivacaine for the surgical repair of a proximal femoral fracture: A prospective, observational trial.

BACKGROUND: Femoral neck fractures usually require operative fixation. Spinal anaesthesia is the preferred technique for many anaesthetists, although single-shot spinal anaesthesia may have severe haemodynamic side-effects. OBJECTIVE: To determine the initial minimum intrathecal dose of 0.5% isobaric bupivacaine required in order to achieve surgical anaesthesia within 15 min. DESIGN: Prospective controlled trial using the Dixon and Massey up-and-down method. SETTING: Patients awaiting surgery for proximal femoral fractures at Cork University Hospital were recruited between September 2012 and December 2012. PATIENTS: With institutional ethics approval and having obtained written informed consent from each, American Society of Anesthesiologists' physical status I to III patients aged more than 60 years were recruited. Twenty-three patients were recruited to the study, of which 22 were managed as per protocol. One patient was excluded because of the inability to insert an intrathecal catheter. INTERVENTION: A 22-guage spinal catheter was inserted between the L3 and L5 vertebral levels. An initial dose of 1 ml 0.5% isobaric bupivacaine was arbitrarily chosen as a starting point. The dose in subsequent patients was determined by the outcome of the preceding spinal block and adjusted by 0.1 ml until data on six independent pairs of patients with successful block/failed block were acquired. MAIN OUTCOME MEASURES: The minimum effective local anaesthetic dose of intrathecal 0.5% isobaric bupivacaine to achieve surgical anaesthesia was defined as the primary outcome. RESULTS: The minimum effective local anaesthetic dose of 0.5% bupivacaine was 0.24 ml (95% confidence interval 0.18 to 0.68). CONCLUSION: Our findings may influence clinicians' initial dose selection for spinal anaesthesia when a spinal catheter is used. The dose may be less than previously thought. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01680120.

Acute compartment syndrome and regional anaesthesia - a case report.

We describe the case of an adult 19 year old male with a fractured right radius. The patient underwent a revision open reduction and internal fixation due to mal-alignment under combined general anaesthesia and supraclavicular brachial plexus block. Postoperatively the patient developed disproportionately intense pain despite an otherwise fully functioning sensory and motor block. The limb was swollen, tender and there was loss of radial pulse. Upon re-exploration a large haematoma was evacuated, a bleeding vessel being the causative factor. There were no further sequellae. The hallmark of this case report is the presence of out-of-proportion pain with an odd distribution in the forearm in the presence of a dense and fully established nerve block. Acute compartment syndrome was diagnosed based on classical signs and symptoms within two hours of block performance. Appropriate treatment lead to satisfactory outcome.

Ipsilateral transversus abdominis plane block provides effective analgesia after appendectomy in children: a randomized controlled trial.

BACKGROUND: The transversus abdominis plane (TAP) block provides effective postoperative analgesia in adults undergoing major abdominal surgery. Its efficacy in children remains unclear, with no randomized clinical trials in this population. In this study, we evaluated its analgesic efficacy over the first 48 postoperative hours after appendectomy performed through an open abdominal incision, in a randomized, controlled, double-blind clinical trial. METHODS: Forty children undergoing appendectomy were randomized to undergo unilateral TAP block with ropivacaine (n = 19) versus placebo (n = 21) in addition to standard postoperative analgesia comprising IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a standard general anesthetic, and after induction of anesthesia, a TAP block was performed using the landmark technique with 2.5 mg · kg(-1) ropivacaine 0.75% or an equal volume (0.3 mL · kg(-1)) of saline on the ipsilateral side to the incision. RESULTS: The TAP block with ropivacaine reduced mean (± SD) morphine requirements in the first 48 postoperative hours (10.3 ± 12.7 vs 22.3 ± 14.7 mg; P < 0.01) compared with placebo block. The TAP block also reduced postoperative visual analog scale pain scores at rest and on movement compared with placebo. Interval morphine consumption was reduced over the first 24 postoperative hours. There were no between-group differences in the incidence of sedation or nausea and vomiting. There were no complications attributable to the TAP block. CONCLUSIONS: Unilateral TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia compared with placebo in the first 48 postoperative hours after appendectomy in children.