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Background
Abdominoplasty surgery is usually performed under balanced general anesthesia (GA). In abdominal surgery, lateral tap block has been used as intra- and post-operative pain control, even if this technique does not successfully cover all of the belly region.
Recent studies have demonstrated the continuity between the thorax and abdomen fascial planes, giving the external oblique intercostal block great expectation in analgesia of the upper abdominal wall.1
Methods
Written informed consent was collected from a 60-year-old female, candidate for abdominoplasty surgery. She had previously undergone a bioenterics intragastric balloon and had no other comorbidities. The external oblique intercostal block was performed, using a linear probe positioned between the midclavicular and anterior axillary lines, at the level of the sixth rib. The transducer was then rotated to obtain a paramedian sagittal oblique view. 15 mL of 0,5% ropivacaine was injected between the plane of the external oblique and the intercostal muscles bilateral. Transversus abdominis plane block with posterior access was then performed to ensure complete analgesia of the lower segments as well with 15 mL of 0,5% ropivacaine bilateral. Then GA with a laryngeal mask was performed.
Results
The patient showed stable vital signs throughout the procedure. In the recovery room, NRS was zero. The following day, she reported a score of 3 on a scale from 1 to 10. No additional opiates were needed.
Conclusion:
The subcostal external oblique plane block has proved to be an excellent technique for peri-postoperative pain control for upper abdominal segments.
References
1. Elsharkawy H, Kolli S, Soliman LM, Seif J, Drake RL, Mariano ER, El-Boghdadly K. The External Oblique Intercostal Block: Anatomic Evaluation and Case Series. Pain Med. 2021 Nov 26;22(11):2436-2442. DOI: 10.1093/pm/pnab296. PMID: 34626112.
Fig. 1 (abstract A28).
A29. ESP-block and general anesthesia in a patient undergoing spine surgery for hyperkyphosis D5-L3: case reportBorrelli G.1, Maria Luisa D.P.1, De Divitiis D.1, Palmieri F.B.1, Galdo V.1, Calabrò G.2
1U.O.C. Anestesia e Rianimazione P.O. San Francesco d'Assisi- ASL Salerno ~ Oliveto Citra ~ Italia, 2U.O.C. Ortopedia e Traumatologia P.O. San Francesco d'Assisi- ASL Salerno ~ Oliveto Citra ~ Italia
Correspondence: Borrelli G.Background
Hyperkyphosis is the condition in which the natural convex curvature of the spine is accentuated. Treatment varies according to the causes that generate it; surgery is indicated when: the curvature exceeds 80 ° Cobb; worsening and disabling pain occurs; the spine is unstable and the progression is constant and fast.
Case report
Patient B.B., female, 71 years old, 68 kg, 168 cm. In medical history: arterial hypertension, ischemic heart disease (hypoperfusion of the anterior wall and stenosis of 50% of the LADA) and anxiety-depressive syndrome. She is admitted to the Orthopedics Department for degenerative dorsal hyperkyphosis and L2 fracture with acupressure pain at the level of the spinous processes and paravetebral dorsolumbar region with positive Lasegue sign on the right and left, difficulty in assuming prone position, DTR AAII bilaterally hypoelicitable, predominantly hyposthenia on the left with reduction of motility. Therefore, she is a candidate for L3-D5 posterior vertebral arthrodesis and stabilization surgery with pedicle screws.
In pre-op room midazolam 2mg i.v. and PONV prophylaxis (pantoprazole 40mg i.v, metoclpramide 10mg i.v.) is administered in peripheral venous access (20G) and a second PVC is inserted (18G).
In the operating room patient is monitored with: ECG, SpO2, NIBP, BIS / Entropy, TOF.
Induction: fentanyl 3mcg/kg, propofol 2mg/kg, rocuronium 0.6mg/kg. At TOF 0 we proceed to orotracheal intubation with 7.5 i.d. armored ETT. Mechanical ventilation in VC-Autoflow mode with Vt 460ml, PEEP 5cmH2O, RR 14 acts/min, I: E = 1: 1.7. The patient is placed prone on the operating table. Maintenance: desflurane (MAC between 0.8 and 1) and remifentanil in TCI (Minto, Ce) and rocuronium boluses equal to 15% of the initial dose at T3 of TOF.
We proceed to bilateral ESP-Block at L3-level with ultrasound-guided technique (convex probe) and atraumatic needle 100mm with caudo-cranial direction, 25ml per side of ropivacaine 0.5% are administered for the block, following the diffusion of the anesthetic.
Before cutaneous incision (carried out 23 min after the block), paracetamol 1g i.v and ketorolac 30mg i.v..
The remifentanil infusion, started with a Ce of 3ng/ml, after about 10min it is reduced to 1.5ng/ml and after 1h it is reduced to 1 ng/ml until it is interrupted at the beginning of the closing phase and begins TAPO with elastomer (2ml/h for 24h) with: ketorolac 90mg, clonidine 150mcg and metoclopramide 10mg. To reverse neuro-muscular blockade, sugammadex 2mg / kg was used.
Total surgery duration: 4h40min. Total anesthesia duration: 5h15min. Time of complete awakening after returning to the supine position: 8min. There was only one episode of significant and hypotension (quickly resolved). After awakening, patient patient was kept in recovery room for 30min and discharged to the ward with spontaneous breathing (FiO2 21%), stable and NRS 3. In the first 24 hours paracetamol 1g i.v. every 6h; then every 8h the next day, finally as needed.
Informed consent has been obtained.
Conclusion
The ESP-block for spine surgery is a valid tool for pain control during and after surgery, as part of a multimodal strategy aimed at minimizing opioid consumption and to allow fast track surgery.
A30. US-guided pudendal nerve block (USG-PNB) as a sole anesthetic tecnique in patients undergoing hemorroidectomy: a preliminary experienceCorso R.M., Aiello L., Maitan S.Anestesia e Rianimazione, Dipartimento Chirurgico, Ospedale GB Morgagni-L. Pierantoni ~ Forlì ~ Italia Correspondence: Aiello L.Background:
Hemorrhoidectomy is a very common surgical procedure, however burdened by a very significant postoperative pain[1]. General or spinal anesthesia using intrathecal morphine is widely used. However there is no strong evidence of the best anesthetic technique[2].
Materials and methods:
Ten consecutive patients scheduled for hemorrhoidectomy were enrolled. After ASA standard monitoring, patients were positioned in the lithotomy position and sedation with propofol TCI started under BIS® monitoring. Then, USG-PNB was perfomed bilaterally using 21gauge 85mm (Echoplex, Vygon) nerve stimulator needle under ultrasound guide. On each side, under aseptic condition, Ropivacaine at the dosage of 0.5%, 20ml was administered. Postoperative scheduled analgesia consisted of Acetominphne 1000mg iv with Tramadol 100mg as rescue analgesia. NRS was used to assess the intensity of pain which was measured between 6 and 24 h postoperatively.
Results:
Postoperatively, all patients had an NRS of less than 4 both at 6 and 24 hours and none needed rescue analgesia. All patients were discharged on postoperative day.
Conclusion:
In times of cost containment and resource optimization, the optimal management of day surgery is fundamental. Hemorrhoidectomy is typically performed in a day-surgery clinic, however suboptimal management of postoperative pain is common leading to increased length of stay and opioid consumption[3]. The pudendal nerve block has already showed a benefit in terms of postoperative analgesia when added to spinal anesthesia[4], but conflicting results have been reported when used alone. Literature data showed the effectiveness of guided US-block compared to finger guided transvaginal pudendal nerve block[5]. In our experience, the use of USG-PNB has allowed optimal pain control without the use of opioids, achieving the goal of day surgery. The technique appears more cost effective than spinal or general anesthesia, avoiding the risks associated with subarachnoid anesthesia and opioids.
References:
[1] Medina-Gallardo A, Curbelo-Peña Y, De Castro X, Roura-Poch P, Roca-Closa J, De Caralt-Mestres E. Is the severe pain after Milligan-Morgan hemorrhoidectomy still currently remaining a major postoperative problem despite being one of the oldest surgical techniques described? A case series of 117 consecutive patients. Int J Surg Case Rep. 2017;30:73-75.
[2] Sammour T, Barazanchi AW, Hill AG; PROSPECT group (Collaborators). Evidence-Based Management of Pain After Excisional Haemorrhoidectomy Surgery: A PROSPECT Review Update. World J Surg. 2017;41(2):603-614.
[3] Lu PW, Fields AC, Andriotti T, Welten VM, Rojas-Alexandre M, Koehlmoos TP, Schoenfeld AJ, Melnitchouk N. Opioid Prescriptions After Hemorrhoidectomy. Dis Colon Rectum. 2020;63(8):1118-1126.
[4] Di Giuseppe M, Saporito A, La Regina D, Tasciotti E, Ghielmini E, Vannelli A, Pini R, Mongelli F. Ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy: a double-blind randomized controlled trial.Int J Colorectal Dis. 2020;35(9):1741-1747
[5] Naja Z, El-Rajab M, Al-Tannir M, Ziade F, Zbibo R, Oweidat M, Lönnqvist PA. Nerve stimulator guided pudendal nerve blockversusgeneral anesthesia forhemorrhoidectomy. Can J Anaesth. 2006 Jun;53(6):579-85
A31. Thymic resection via median sternotomy: ultrasound-guided bilateral parasternal block could be effective?Pagani G.1, Giordano C.2, Brambillasca P.3, Perletti S.1, Gera E.1, Mulas E.2, Rasella B.2, Cadei M.2, Mario C.2 1Resident of Anesthesia and Intensive Care, Department of Medical-Surgical, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy ~ Brescia ~ Italia, 2Anesthesia and Intensive Care Unit, Emergency and Critical Care Department, ASST Papa Giovanni XXIII, Bergamo, Italy ~ Bergamo ~ Italia, 3Anesthesia and Intensive Care Unit, Emergency and Critical Care Department, Fondazione IRCCS Cà Grande Ospedale Maggiore Policlinico, Milano, Italy. ~ Milano ~ Italia Correspondence: Pagani G.A 30-year-old male presented ataxia, nystagmus, blurred vision, right-ear hearing loss and a positive Romberg test with 10 kg weight loss.
Anti-HU paraneoplastic syndrome was suspected and intravenous immunoglobulin started with slight improvement of neurological symptoms.
Total body PET scan was performed which showed hyperfixation area in the anterior-superior mediastinum, indicative of thymoma. After a written informed consent was obtained, the patient underwent thymectomy via median sternotomy. Impaired pulmonary function which can lead to pulmonary infection and atelectasis due to severe postoperative pain is shown in the literature.
We examined the efficacy of ultrasound-guided parasternal block (Us-PsB), a novel regional anesthetic technique, in preventing these complications, proved to deliver analgesia to the antero-medial chest wall, by blocking the anterior cutaneous branch of the intercostal nerves and consequently ventilation improvement.
After induction of general anesthesia, with the patient in the supine position, we performed the Us-PsB using a high-frequency linear transducer (12-MHz).
The probe was placed longitudinally 2 cm lateral to the sternal border, visualizing the 2nd intercostal space, Pectoral Major muscle(PMM), External Intercostal muscle (eiM), the second rib and the pleura. The in-plane approach was applied with a 22-gauge, 100-mm needle. A solution of 30 ml Ropivacaine 0,2% and, as adjuvant, dexmedetomidine75 mcg and dexamethasone 4 mg were injected into the interfascial plane between PMM and eiM at the level of the 2nd intercostal space bilaterally.
Anesthesia was maintained with desflurane 0.9 MAC and intraoperative hemodynamic stability was observed.
Before the end of surgery, intravenous injection of acetaminophen 1 gram and ketorolac 30 mg were administered.
After surgery and extuation, hemodynamic stability was maintained and the patient reported prolonged pain relief. Pain score(Numeric Rating Score -NRS- scale of 0-10 where 0=no pain and 10=maximum pain) was used to assess postoperative pain. Postoperative analgesia consisted of acetaminophen 1 gram and ketorolac 30 mg,both every 8 hours in the first 24 hours, while no rescue therapy was needed.
In the first 48 postoperative hours, the patient reported no pain at rest(NRS 0/10) with slight pain on movement (NRS 2/10). No discomfort, neurological symptoms or other complications were recorded in the postoperative period.
Us-Psb and the co-administration of local anesthetic with dexmedetomidine and dexamethasone,as adjuvants, in this particular case for a thymic resection via median sternotomy provided adequate and prolonged analgesia for up to 48 hours with no side effects.
US-PSb and the use of dexmedetomidine and dexamethasone as adjuvants appeared to be an effective approach for post-operative analgesia in this surgery, but future studies will be needed.
A32. Ultrasound-guided quadratus lumborum block type II vs erector spinae plane block on postoperative pain and opioid consumption after laparoscopic adrenalectomyPerletti S.1, Brambillasca P.2, Consuelo M.2, Personeni N.2, Gera E.2, Cadei M.2, Mulas E.2, De Gaetano P.2, Pagani G.2, Rasella B.2, Giordano C.2 [1]Resident of Anesthesia and Intensive Care, Department of Medical-Surgical, Radiological Sciences and Public Health, University of Brescia ~ Brescia ~ Italia, [2]Anesthesia and Intensive Care Unit, Emergency and Critical Care Department, Fondazione IRCCS Cà Grande Ospedale Maggiore Policlinico ~ Milano ~ Italia Correspondence: Perletti S.Ultrasound guided Quadratus Lumborum Block type II (QLB II) and Erector Spinae Plane Block (ESPB) are novel techniques which prove to be effective for postoperative analgesia in patients undergoing laparoscopic abdominal surgery.
We evaluated analgesic effectiveness of these interfacial plane blocks in two patients scheduled to undergo right laparoscopic adrenalectomy for adrenal tumor, evaluating postoperative pain and cumulative opioid requirement at 24th hours.
Written informed consent was obtained. The first patient was a 66 years old male with hypertension and chronic obstructive lung disease. The second, a 67 years old male with hypertension and insulin-dependent diabetes. We induced general anesthesia with fentanyl 1.5 mcg/Kg, propofol 2 mg/Kg and rocuronium 0.6 mg/Kg in both patients. After induction, we proceed with loco-regional techniques.
In case 1, ultrasound guided QLBII was performed with the patient in supine position. A curvilinear ultrasound probe was placed cephalad and parallel to the iliac crest and moved posteriorly until Quadratus Lumborum muscle was clearly identified. A 100 mm Pajunk needle was inserted in the plane with lateral to medial direction. We injected 20 ml of 0,325% Ropivacaine and 4 mg of dexamethasone, as an adjuvant, bilaterally in the fascial plane between the quadratus lumborum muscle and the latissimus dorsi muscles.
In case 2, we performed ultrasound guided ESPB. The patient was in the left lateral position for the surgery. The right T12 transverse process was identified using a high-frequency linear probe. A 100 mm Pajunk needle in-plane was inserted and 25 ml of 0.325 % ropivacaine and 4 mg of dexamethasone, as an adjuvant, were injected in the deep plane of the erector spinae muscle.
Maintenance of anesthesia was achieved with sevoflurane (0,8 MAC). Acetaminophen 1 gram intravenous was administered before patients awakening in the operating room.
In the postoperative period, we reported pain intensity using the NRS scale at 24th hour after surgery and the opioid requirements. In case 1, analgesia was provided with acetaminophen 1 g 8 hourly, ketorolac 30 mg 8 hourly and tramadol 100 mg 12 hourly with NRS >3.
Patient in case 2 had prolonged pain relief (NRS < 3) and required 3 g of acetaminophen and ketorolac 90 mg, sparing opioid use.
No complications were recorded in the postoperative period in both patients. In our case reports the patient receiving ESPB had a decreased postoperative opioid consumption in the first 24 hours and reduced NRS scores compared to QLBII.
In literature there is no case report comparing ESP and QLBII in this surgery. The excellent control of somatic and visceral pain obtained with ESPB is likely due to the spread of local anesthetic that, despite it being unpredictable and not guaranteed, is focused on a specific level of thoracic paravertebral space. However, the comparison of ESPB and QLB-II in this surgery is still a topic to be evaluated by further studies in order to confirm whether ESPB could be more effective than QLBII for laparoscopic adrenalectomy.
A33. Top/Subcostal QLB: a top block for top pain control in a laparoscopic nephrectomyRemore L.M., Costa F., Strumia A., Cataldo R., Pascarella G., Di Folco M., Ruggiero A., Sarubbi D., Longo F., Agrò F.E.Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico ~ Roma ~ Italia Correspondence: Remore L.M.Background and aims
Quadratus Lumborum Block (QLB) is based on the injection of local anesthetic (LA) into the toracolumbar fascia (TLF) surrounding the quadratus lumborum muscle. The spread of LA along the TLF into the thoracic paravertebral space and transversalis fascia provides analgesia without neuraxial-associated hypotension; this is mostly effective for patients undergoing abdominal and hip surgeries. There are four types of QLB based on injection sites: lateral, posterior, transmuscular and intramuscular. Transmuscular QLB, or QLB3, can be performed at L4 and L2 level using the subcostal approach. Our aim is to assess the efficacy and viability of the subcostal QLB approach for laparoscopic nephrectomy.
Methods
We selected a patient listed for a laparoscopic nephrectomy, male, ASA score II, BMI 27. After obtaining consent we performed bilateral QLB with subcostal approach. We injected a solution of 30ml ropivacaine 0,37 mg/ml for each block (a total of 225 mg ropivacaine) to ensure optimal spread and proper anesthetic concentration. A bolus of 100 μg fentanyl was the only opioid administered for general anesthesia induction. We used BIS and NOL Pain Response Monitor during surgery to assess the need of further opioids administration. The primary outcome was the consumption of opioids in the first 24h after surgery. The secondary outcome measured were heart rate and median arterial pressure during the surgery, intraoperative consumption of remifentanil, VAS score at 1, 3 and 6 hours after surgery, Bruggeman comfort scale (BCS) at 12 and 24 hours and presence of side effects.
Results
No opioid administration was needed during surgery, VAS scores were never over 2, BCS always between 3 and 4 and no side effects were observed. We prescribed an analgesic therapy comprised of paracetamol 1g tid and ketorolac 30mg tid in the post-operative period. No other painkillers or opiates were administered.
Conclusion
This regional anesthesia strategy seems to be promising and satisfactory, providing optimal post-operative analgesia and easier intra-operative management. Studies are needed to implement this strategy and compare its outcomes to traditional general anesthesia.
Fig. 1 (abstract A33).
A34. Sedative and hemodynamic effects of target-controlled infusion of propofol and dexmedetomidine using ultrasound-guided regional anesthetic technique for mastectomy and axillary dissectionDe Gaetano P.2, Perletti S.2, Personeni N.2, Pagani G.2, Gera E.2, Giordano C.1, Mulas E.1, Rasella B.1, Cadei M.1, Brambillasca P.3, Mario C.4
1Anesthesia and Intensive Care Unit, Emergency and Critical Care Department, ASST Papa Giovanni XXIII ~ Bergamo ~ Italia, 2Resident of Anesthesia and Intensive Care, Department of Medical-Surgical, Radiological Sciences and Public Health, University of Brescia ~ Brescia ~ Italia, 3Anesthesia and Intensive Care,Emergency and Critical Care Department, Fondazione IRCCS Cà Grande Ospedale Maggiore Policlinico ~ Milano ~ Italia, 4Director of Anesthesia and Intensive Care Unit 1, Emergency and Critical Care Department, ASST Papa Giovanni XXIII ~ Bergamo ~ Italia
Correspondence: De Gaetano P.It has recently been demonstrated that general anesthesia in breast surgery could promote metastasis of cancer cells and, moreover, determines peri-operative complications. Therefore, the identification of different anesthesiological approaches to breast surgery could be relevant. We introduced in our clinical practice a standardized sedation protocol. Intra-operative a highly selective alpha-2 adrenergic agonist, dexmedetomidine(DEX), was used and a load of 1 μg/kg/h in 15 minutes, followed by a continous infusion of 0,6 - 0,3 mcg/kg/h, was administered. In association, intravenous sedation using target controlled infusion(TCI) of propofol with Schnider pharmacokinetic model was started. The effect-site target concentration of propofol was set and was maintained at 1.5 μg/ml. Before surgery, we performed the ultrasound Serratus Plane Block(US-SPB), with injection of 20 ml of 0,75% ropivacaine and 0,5 mcg/kg of DEX in the fascial plane deep of the serratus anterior muscles at the fifth rib level and, subsequently, ultrasound- Pectoralis nerve(US- PECS 1), injecting 10 ml of 0,75% ropivacaine and 0,5 mcg/kg of DEX in the fascial plane between the pectoralis major and minor muscles at the third rib level. We observed the sedative and hemodynamic effects and peri-operative complications in 7 patients with the mean age of 65 years, severe obesity, affected by anxious depressive syndrome or psychiatric illness and other diseases, ASA III (Imagine 1), undergoing radical mastectomy with axillary dissection from June to August 2021. During surgery, oxygen saturation, respiratory rate, end-tidal carbon dioxide (EtCO2) monitoring, non-invasive blood pressure and consciousness with Bispectral index- BIS, used to monitor depth of anesthesia (ranges from 0 -equivalent to EEG silence- to 100 -patient conscious), were continuously measured and evaluated. After surgery, a quick awakening was recorded and the patients were transferred to a recovery room where blood pressure and oxygen saturation were continuously monitored for at least 30 minutes until meeting discharge criteria. In the first 24 hours prolonged pain relief, Numeric Rating Scale-NRS 2 (0 indicates no pain and 10 indicates the worst pain), no anxiety and post-operative complications were observed (Image 2). Only 3 g of acetaminophen were administered and shorter recovery time were reported. They were discharged on the following day after surgery.
Nor hypercarbia neither hypoxia or apnea events and hemodynamic stability, no pain, excellent comfort and no peri-postoperative complications were reported.
We believe that this sedation protocol could be an effective method that doesn’t cause excessive plasma concentration of both sedatives drugs, no respiratory depression, no anxiety and hypotension. This drug combination ensure intra-operative spontaneous breathing and hemodynamic stability with excellent comfort for the patients, without peri-operative complications. Further studies are necessary to externally validate findings.
Table 1 (abstract A34). Patients characteristics and comorbidity Table 2 (abstract A34). Results of sedation associated to ultrasound-guided thoracic fascial plane block A35. Fascial plane blocks for intra and post operative analgesia after breast augmentation vs general anesthesia: a randomized clinical trialD'Errico C.1, Sabatella E.1, Frangiosa A.1, Belfiore F.1, Di Costanzo M.2 1Dipartimento di Anestesia e Rianimazione, AORN Cardarelli ~ Napoli ~ Italia, 2AOU L. Vanvitelli ~ Napoli ~ Italia Correspondence: D'Errico C.Background and objectives: We chose PECs I and ESP block as fascial block in breast augmentation surgery with implant of subpectoral protheses, one of the most common surgical procedures in this field.
Methods: We selected 20 patients ASA I-II undergoing breast augmentation for aesthetic purposes. They were randomly divided in 2 groups: the general anesthesia group (GA group, n=8) and the fascial block group (FB group, n= 12). Both groups were premeditated with midazolam 5mg IV. The GA group received general anesthesia with: propofol IV (2mg/kg IBW), rocuronium bromide IV (0,6mg/kg IBW), remifentanil in continuous IV administration (between 0,15-0,25mcg/kg IBW/min). Endotracheal intubation was performed with armed cuffed tube (for women with a diameter between 7.0 - 8.0 mm and for men between 7.5 - 8.5 mm) with mechanical ventilation using SpO2 >97% as an endpoint and sevoflurane tritrated with BiSpectral Index (BIS) values. The FB group received Erector Spinae Block bilateral with injection of 20 ml of 0.75% ropivacaine for each side with a 22G 70mm needle, paraspinal level T5-T6. To reach an appropriate intraoperative analgesic regimen with the insertion of subpectoral prostheses, PECS I block was added injecting 10 ml of 0.75% ropivacaine for each side into the fascial area between the Pectoralis Major muscles (PMm) and Pectoralis minor muscles (Pmm) with a 22G 70mm needle. The patients of the FB group were in spontaneous breathing, in case of SpO2 <94% we complemented ventilation with a LMA insertion previous administration of propofol 1- 2mg/kg IBW. In case of incomplete block coverage (NRS>6) fentanyl IV between 0,5 and 1 mcg/kg IBW was given.
In the operating room, all patients received continuous standard monitoring (PA, FC, ECG with at least 2 leads displayed, SpO2) and BIS™ monitor. Post operative pain was evaluated with NRS and its management was performed for the GA group with Acetaminophen 1g IV TID and continuous infusion of Contramal 400mg and Ondasentron 8mg in the 24h following the surgery. A rescue therapy was planned for the GA group with Toradol IV 30mg if NRS> 4.
Results and discussion: We assessed post operative pain with NRS scale at 1, 2, 6, 12 and 24 hours intervals. During surgery the hemodynamic parameter of both groups were similar. In the 24h following the surgeries for the FB group a rescue analgesia was administered only to 2 patients and opioid drugs weren’t required. In the GA group, despite the continuous infusion, opioid were needed, thus confirming that the analgesic duration and stability of a Fascial Plane Block technique was longer. The rates of nausea and vomiting were higher in GA group than in IFB group. No block-related complications were recorded.
Conclusions: Fascial nerve blocks provide effective perioperative pain relief after aesthetic breast surgery and is associated with reduced need for analgesic drugs and post operative pain, reduction of PONV episodes with a safety profile regarding block-related complication.
Combined use of ESP and PECS I provide superior postoperative analgesia in patients undergoing breast augmentation with insertion of subpectoral prostheses and shortens hospital stay.
Fig. 1 (abstract A35).
A36. Observational preliminary study: use of dexmedetomidine in patients undergoing orthopedic surgery of upper limb in loco-regional anesthesiaZumpano A., Caruso M.T., Tangari R., Bonadio F., Monardo A.Ospedale Giovanni Paolo II, dipartimento di Anestesia e Rianimazione ~ Lamezia Terme ~ Italia
Correspondence: Zumpano A.Background. Dexmedetomidine is a very selective agonist of alpha2-receptors, used in continous infusion. Sedative effects are mediated by inhibition of the activity of Locus Coeruleus, which is the main noradrenergic centre, located in the brainstem. Administered in monotherapy dexmedetomidine hasn’t effect on respiratory drive and this make the drug extremely safe in the sedation of patients undergoing surgery in loco-regional anesthesia.
Outcomes. Main outcome an assessment of dexmedetomidine sedative effects and its hemodynamic stability in patients undergoing orthopedic surgery during loco-regional anestesia. The secondary outcome of the study was the evaluation of a possible use of non-invasive specific monitoring of sedation level to determine the most appropriate infusion dosage of dexmedetomidine.
Patients and methods. The enrollment period considered was October 2021-February 2022. 10 patients were included in the study, all adults candidates for orthopedic surgery of the upper limb performed in loco-regional anesthesia with an ultrasound-guided peripheral nerve block of brachial plexus.
The non-invasive monitoring system Conox® were used for the evaluation of sedation level. The study protocol involved the application of monitoring immediatly in the pre-op room. Dexmedetomidine infusion was started using a dedicated venous line and a syringe-pump. The start dosage was 0,7mcg/kg/h and the sedation target considered was qCON 80-70, so the infusion dosage was modulated on the target qCON value. Local anestetic used were: Levobupivacaine 0,5% and Lidocaine 1% for a total volume of 20ml.
Conox® monitoring was maintained in place for the assessment of the timing of recovery of basal values. NRS (Numerical Rating Scale) was used for evaluation of analgesia. Administration of Paracetamol 1g or Diclofenac 75mg it was expected in NRS >3.
Results. Patients didn’t report disconfort during their stay in pre-op room, while performing the peripheral block, during surgery and in recovery room. Severe bradycardia was observed in 60% of cases and has been resolved giving atropine 0,5mg iv. Variations in blood pressure were not observed. Episodes of desaturation were observed in 40% of cases, in particular were patients affected by moderate obesity ad OSAS. In follow-up period patients required Paracetamol 1 g iv or Diclofenac 75mg iv only after 14-24hrs for NRS between 4-7; NRS >3 was observed in the first 12hrs after surgery.
Conclusion. Analyzing the collected data we can claim that a sedation with continuous infusion of dexmedetomidine could be useful in support of the techniques of loco-regional anesthesia for interventions of medium-long duration. The timing of reaching the target value of qCON does not make its use advantageous for surgery of short duration. We can also conclude that monitoring of level of sedation used has allowed us to modulate accurately the dosage of the infusion, minimizing side effects and ensuring adequate sedation during all procedures.
A37. Intrathecal morphine associated to tap block in laparoscopic robot-assisted resection of gastrointestinal stromal tumors (LRA-GIST): our experienceAiello L.1, Gori A.1, Ione E.2, Corso R.M.1, Maitan S.1 1Anestesia e Rianimazione, Dipartimento Chirurgico, Ospedale GB Morgagni-L. Pierantoni ~ Forlì ~ Italia, 2Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara ~ Ferrara ~ Italia Correspondence: Aiello L.Background:
GISTs are less aggressive than tumors elsewhere, especially those in small intestine[1]. Literature report feasibility and benefits of minimally invasive surgery, in terms of outcome and low mortality and morbidity rates[2]. Robotic surgery, provides favorable peri-operative results compared to open and laparoscopic surgery[3].
Materials and methods:
Prospective observational study of ten consecutives patients scheduled for LRa-GIST; the average age of the patients was 68±2 years and they did not show substantial differences in anthropometric characteristics. Patient informed consent was obtained one week prior to surgery. All patients underwent standard monitoring. Before general anesthesia, patients received spinal analgesia with 100mcg of morphine and Levobupivacaine 7,5mg in total volume of 3ml in saline solution at the T9–T10 level, using a 25 Gauge Withacre needle. General anaesthesia was induced with fentanil 0.2μg/kg and propofol 2mg/kg and rocuronium 0.6mg/kg. Then, modified US-TAP block was performed using a total of 40ml of Ropivacaine 0.5%[4]. Anesthesia was then maintained with Desflurane adjusted according to the BIS value. Intraoperatively no other opioids were administered. Neuromuscular block status was monitored by datex-Ohmeda monitor stimulator. At the end of surgery and under TOF suggestion, 2mg/kg of Sugammadex was administered. Acetominophen at the dose of 1gr, was administered 15minutes before the end of the surgery. Acetominophen 1gr every 8 hours daily was planned for postoperative analgesia. At rest and dynamic post-operative NRS was measured at 6,12,18,24,36,48 and 72hours postoperatively.
Results:
Very low opioids dose were administered to all patients. In the first 24hours, all patients received Acetominophen 3gr as scheduled. In the following 2days, no pain relief was needed and no patients complained of PONV.
Conclusion:
The benefit of the TAP block in robot-assisted laparoscopic surgery and the beneficial effect of intrathecal administration of low-dose morphine had already been demonstrated[4-5]. Literature, largely suggests the use of opioid sparing anaesthesia to improve patient’s outcomes and to reduce costs. We conclude that this anesthesiological approach for LRa-GIST resection, is safe, well tolerated, provides intraoperative lower opioid requirements, ensures postoperative analgesia and reduces PONV, according to ERAS protocol. However, further larger studies are necessary to clarify the effective role of different anesthesiological strategies in LRa-GIST.
References:
1. Miettinen M., Lasota J. Review gastrointestinal stromal tumors:pathology and prognosis at different sites. Semin Diagn Pathol 2006; 23: 70–83
2. Nguyen S.Q., Divino C.M. Laparoscopic management and long term outcomes of gastrointestinal stromal tumors. J Am Coll Surg 2009; 208(1): 80–86
3. Desiderio J., Trastulli .S, Cirocchi R., et al. Robotic gastric resection of large gastrointestinal stromal tumors. Int J Surg 2013; 11(2):191–196
4. Dal Moro F., Aiello L., Pavarin P., Zattoni F. Ultrasound-guided transversus abdominis plane block (USTAPb) for robot-assisted radical prostatectomy: a novel ‘4-point’ technique—results of a prospective, randomized study. Journal of Robotic Surgery. https://doi.org/10.1007/s11701-018-0858-6
5. Gori A., Aiello L., Bellantonio D., Pitrè C., Dima V., Piccinno M., Corso R.M., Maitan S.. Intrathecal morphine and abdominal wall blocks reduces analgesic consumption and postoperative nausea and vomiting (PONV) in robotic-assisted laparoscopic prostatectomy (RALP). RAPM 2019;44(Suppl 1):A1–A27. 10.1136/rapm-2019-ESRAABS2019.470
A38. Comparative study of locoregional anesthesia (ESP block + serratus plane block + parasternal block) versus postoperative intravenous analgesia for total mastectomyGiurazza R.1, Falso F.1, Coppolino F.1, Pota V.1, Sansone P.1, Pace M.C.1, Corcione A.2, De Rosa R.C.2, Passavanti M.B.1 1AOU "Luigi Vanvitelli" - Scuola di Specializzazione in Anestesia, Rianimazione, Terapia Intensiva e del Dolore ~ Napoli ~ Italia, 2AORN dei Colli - Dipartimento di Area Critica ~ Napoli ~ Italia Correspondence: Giurazza R.Background: Breast cancer is the most common cancer in women. Breast surgery can be very painful in the postoperative phase, leading to high consumption of analgesics (NSAIDs and opioids). This is even more accentuated in case of total mastectomy, with implantation of breast tissue expanders. In recent years, locoregional anesthesia has significantly improved postoperative pain control and complications, with lower use of postoperative analgesics and better patient compliance.
Methods: We performed a prospective comparative study of women, undergoing total mastectomy with implantation of expander due to breast cancer. The patients were randomly allocated to two groups: (1) group A, receiving intraoperative analgosedation (LMA) using desflurane and remifentanil and postoperative analgesia with acetaminophen 1 g q8h, ketorolac 90 mg/die, tramadol 200 mg/die and metoclopramide 20 mg/die; (2) group B, receiving preoperative ultrasound-guided ESP block (level T4 with levobupivacaine 0.375% 20 mL + dexamethasone 4 mg ), serratus plane block (levobupivacaine 0.25% 20 mL + dexamethasone 2 mg) and parasternal block (levobupivacaine 0.25% 10 mL + dexamethasone 2 mg) and intraoperative sedation (LMA) with desflurane only and without remifentanil. In both groups, in case of postoperative pain, morphine 5 mg iv was used as rescue medication. We examined postoperative pain with NRS at emergence of anesthesia (t0), at 6 hours (t1), at 12 hours (t2) and at 24 hours (t3), as well as use of rescue medication for pain in both groups. Data were compared using Mann-Whitney U test and statistical significance was accepted if p value was <0.05. Informed consent to publish was obtained by all participants to the study.
Results: A total of 24 patients were included in the study, 11 in group A and 13 in group B, with no significant differences of age and ASA status between the two groups. In group A and group B, mean NRS at t0 was 5.4 vs 2.3 (p value .0003), at t1 4.4 vs 2.1 (p value .0006), at t2 3.7 vs 2.6 (p value .034), at t3 3.4 vs 2.7 (p value .11, not statistically significant), respectively. Mean morphine rescue use was significantly higher in group A than in group B (respectively, 7.7 mg vs 1.3 mg, p value .024).
Conclusions: Our experience, although limited, shows that pain NRS in women undergoing total mastectomy with implantation of breast tissue expanders is significantly lower in those treated with locoregional anesthesia than in those who received standard postoperative intravenous analgesia. The statistical significance for NRS is lost 24h after the end of surgery, probably because at this time the effect of locoregional anesthesia is vanished. Moreover, in the locoregional anesthesia group mean consumption of opioids is significantly lower, with fewer side effects and better safety profile.
Table 1 (abstract A38). See text for description A39. An innovative ultrasound-guided dorsal penile nerve block for pediatric urologic surgeryPilia E.1, Rufini P.2, Cumbo S.2, De Donato F.3, Ricci Z.4 1Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy ~ Cagliari ~ Italia, 2Department of Anesthesiology and Critical Care Medicine, Pediatric Intensive Care Unit, Meyer Children's Hospital, Florence, Italy ~ Firenze ~ Italia, 3Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan Italy ~ Milano ~ Italia, 4Department of Health Science, University of Florence, Florence, Italy ~ Firenze ~ Italia Correspondence: Pilia E.Background
In pediatric population, surgery of penis is one of the most common urologic procedures and it causes significant intra and postoperative pain. We propose an innovative ultrasound (US) technique named reversal US-guided dorsal penile nerve block (R-US-DPNB). Our aim is to evaluate the efficacy and safety of R-US-DPNB in pediatric penile surgery compared to Dalens DPNB.
Materials and methods
After establishing general anesthesia, we performed the RUS-DPNB technique using a linear ultrasound probe covered with transparent film and sterile gel. The probe was positioned along the transverse plane, between the root of the penis and the scrotum, slightly angled in a cranial direction towards the pubic symphysis (Fig 1A shows penile US visualization). The anatomical structures are mirrored, and, for this reason, we named this technique reversed US-guided block. An echogenic atraumatic needle (22Gx5cm) is than inserted lateral to the probe and the use of an in-plane technique allows to see the needle tip as a hyperechoic structure while slowly advancing to the target (Fig 1B-C). After a negative aspiration test, an injection of 2 mL of local anesthetic (1 ml LA per each side for children weighing up to 10 kg and then an additional ml for every 10 kg) is performed, separating the deep fascia of the penis from the adjacent tissues (Fig 1D). The needle is then slowly retracted to inject LA to the other side (Fig 1E) and to obtain the spread of LA all-around penile structures (Fig 1F). The block is followed by the application of 2 mL of topical 2% Lidocaine to the foreskin to ensure frenulum analgesia. We evaluated opioid requirements for hemodynamic variations associated with pain, time of execution, complications rate and opioid administration. Postoperative pain has been evaluated using the VAS/FLACC scale.
Results
We retrospectively evaluated 63 patients: 40 patients received R-US-DPNB and 23 patients received Dalens DPNB block.. In the R-US-DPNB group the 12.5% of patients showed hemodynamic variations vs 70% in the Dalens DPNB group (p<0.0001). Fentanyl bolus requirement in Dalens DPNB group was higher (11% vs 77%, p=0.0002). LA volume used to perform the block was reduced in R-US-DPNB (0.13 ml/kg vs 0.34 ml/kg, p<0.0001). The Dalens group showed shorter execution times (3 min vs 2 min, p=0.0001). No serious complications were observed in any patient. Overall postoperative pain control was similar in both groups, even if R-US-DPNB showed lower pain scores 3h after surgery (17% vs 30% with a score>0, p=0.0006).
Conclusions
The intraoperative analgesic effect of R-US-DPNB is higher than Dalens DPNB, is associated with a lower failure rate and a lower use of LA volume to perform the block. The postoperative analgesia of R-US is comparable to Dalens DPNB. We propose R-US-DPNB as a valid and safe alternative to landmark approach.
Fig. 1 (abstract A39).
R-US-DPNB technique performed using a linear ultrasound probe (13-6 MHz, 38mm, SonoSite). The corpus spongiosum (1). The two corpora cavernosa (2). Arteries, veins, and the two dorsal nerves of the penis run within the Buck’s fascia (3). X: target. LA: local anesthetic
A40. "Peng block" vs "FNB + ONB" in the patient with femur fracture who is not a candidate for neuraxial anesthesiaGargano F.1, Bellezze A.1, Ruggiero A.1, Strumia A.1, Galderisi A.1, Borrelli G.2, Citriniti V.1, Carassiti M.1, Agrò F.E.1 [1]nit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico ~ Roma ~ Italia, [2]U.O.C. Anestesia e Rianimazione P.O. San Francesco d'Assisi ~ Oliveto Citra (Salerno) ~ Italia Correspondence: Bellezze A.Background
Locoregional anesthesia is widely used in orthopedic surgery, particularly in traumatology, where surgical indications are relatively common, especially in the elderly, and are associated with significant morbidity and mortality 1.
Ensuring proper anaesthesia in high-risk patients who have suffered a proximal femur fracture can be difficult.
The ideal blocking technique should provide complete analgesia of the hip joint without leading to muscle weakness.
First described in 2018, the PENG block (Pericapsular Nerve Group Block) is an analgesic technique used predominantly in total hip arthroplasties for postoperative analgesia with the advantage of motor sparing 2.
Clinically, the efficacy of the PENG block for analgesia in patients with hip fracture has already been demonstrated 3. The study aims to evaluate the anesthetic efficacy of the PENG block.
Materials and methods
The study population consisted of 40 patients with a proximal femur fracture, who were not candidates for neuraxial anesthesia and underwent reduction and synthesis surgery at the UCBM Trauma Unit.
According to a randomization model, the patients were divided into two groups: In the first group, a PENG block was performed 30 minutes before the patient was placed on the operating table, with Ropivacaine 0.5% (20 ml). In the second group, FNB (Femoral Nerve Block) with Ropivacaine 0.5% (15 ml) and ONB (Obturator Nerve Block) Ropivacaine 0.5% (5 ml) were performed.
All patients received the same multimodal analgesia protocol, in addition, skin access point infiltration with Ropivacaine 0.5% (20 ml) was performed.
Outcomes were recorded using the NRS scale as the primary outcome, intra- and postoperative opioid consumption was also collected, and a ROM study was performed to assess joint flexibility.
Results
Ten cases were collected and randomized into the two intervention groups. Applying the t -student for the NRS scale of pain measured at 30 minutes, recovery room, 6,12, and 24 hours after the anesthetic block, there was no difference between the arithmetic averages of the two groups in all pain outcomes. There was no difference in opioid consumption and no need for increased sedation.
Conclusions.
Finally, no superiority was demonstrated for the PENG group, but being preliminary data together with the small number of studies on the anesthetic efficacy of this technique, not finding any particular differences between the averages is a satisfactory result and gives good grounds for the assumption.
After the study, we expect similar results for the other outcomes measured.
Finally, we demonstrate the use of PENG as a valid alternative to femoral and obturator blockade.
1. Lee DJ, Elfar JC. Timing of hip fracture surgery in the elderly. Geriatr Orthop Surg Rehabil. 2014 Sep;5(3):138-40.
2. Berlioz BE, Bojaxhi E. PENG Regional Block. [Updated 2021 Mar 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565870/
3. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018 Nov;43(8):859-863.
Fig. 1 (abstract A40).
A41. Bilateral ultrasound-guided quadratus lumborum block combined with rectus sheath block for elective open abdominal aortic surgery: a pilot studyNatta S.3, Melchiorri C.1, Bevacqua C.2, Caironi P.4, Balagna R.1
1Department of Anaesthesia and Intensive Care, A.O.U. Città della Salute e della Scienza ~ Torino ~ Italia, 2Humanitas Ospedale Gradenigo ~ Torino ~ Italia, 3University of Turin; Department of Anasthesia and Intensive Care, AOU Città della Salute e della Scienza ~ Torino ~ Italia, 4University of Turin; Department of Anaesthesia and Critical Care, A.O.U. San Luigi Gonzaga ~ Orbassano (TO) ~ Italia
Correspondence: Natta S.Background
Epidural analgesia (EA) has proven superior to systemic opioids for postoperative management of patients undergoing elective open abdominal aortic surgery in terms of pain control, reduced cardiac and respiratory complications, and ICU length of stay [1]. However, EA has some well-defined contraindications (i.e., bleeding disorders, medications, sepsis, history of spinal surgery, severe spinal arthrosis), and aortic surgery itself carries additional risks related to the intraoperative need for anticoagulation. In this setting, fascial plane blocks recently emerged as alternative analgesic techniques when epidural catheterization has failed or is contraindicated. In particular, quadratus lumborum block (QLB) showed efficacy in postoperative multimodal pain strategies in different abdominal surgical procedures [2,3].
In this pilot study, we evaluated the efficacy of bilateral QLB combined with rectus sheath block (RSB) in managing postoperative pain after elective open abdominal aortic surgery.
Materials and methods
Nine male patients [median age: 72 years (range 56-79)] undergoing elective open abdominal aortic surgery were selected to receive bilateral posterior QLB combined with RSB before surgical incision. Standard anaesthetic management was inhaled general anaesthesia. QLB and RSB were performed under US-guidance, bilaterally injecting 20 ml of 0,375% ropivacaine and 10 ml of 0,375% ropivacaine, respectively. Intraoperative need for opioids was evaluated case-by-case. All patients received 1g paracetamol and 100mg tramadol before the end of surgery. ICU early postoperative monitoring was performed, providing paracetamol 3g/day and tramadol 200 mg/day as postoperative analgesia. Pain was evaluated with the numeric rating scale (NRS; range: 0-10) at awakening (NRS-0), and at 6 (NRS-6), 12 (NRS-12), and 24 (NRS-24) hours after surgery, as well as the need for rescue analgesic medications (intravenous morphine).
Results
No complications were observed while performing QLB (Figure 1A). All patients were admitted to ICU, but one was excluded from our analysis because of prolonged (>24 hours after surgery) sedation. Mean NRS resulted as follows: NRS-0 1.38 (SD 2.56), NRS-6 0.00 (SD 0.00), NRS-12 0.38 (SD 1.06), and NRS-24 0.00 (SD 0.00). NRS-0 scored >4 in two patients, thus requiring morphine rescue analgesic dose (Figure 1B). Three patients required intraoperative opioid infusion (sufentanil, mean dose: 0,17 mcg/kg/h), but no significant difference was observed in terms of NRS 0 (p=0.82) and NRS 12 (p=0.48) compared to the other group. Of note, NRS-6 scored identical within the two groups (Table 1).
Conclusions
Bilateral QLB combined with RSB in a multimodal analgesia regimen setting can be considered an effective alternative to epidural analgesia for postoperative pain management in elective open abdominal aortic surgery patients. Based on this data, we aim to develop a prospective randomized clinical trial to evaluate QLB and RSB use compared to systemic opioids for postoperative pain management of elective abdominal aortic surgery patients.
Written informed consent for the publication was obtained from every participant.
Acknowledgements: None.
References
1. Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2016 Jan 5;2016(1):CD005059. doi: 10.1002/14651858.CD005059.pub4. PMID: 26731032; PMCID: PMC6464571.
2. Ueshima H, Otake H, Lin JA. Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques. Biomed Res Int. 2017;2017:2752876. doi: 10.1155/2017/2752876. Epub 2017 Jan 3. PMID: 28154824; PMCID: PMC5244003.
3. Elsharkawy H. Quadratus Lumborum Blocks. Adv Anesth. 2017;35(1):145-157. doi: 10.1016/j.aan.2017.07.007. Epub 2017 Oct 3. PMID: 29103570.
Table 1 (abstract A41). Case series characteristics
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