Thoracic paravertebral block for postoperative pain management in percutaneous nephrolithotomy patients: a randomized controlled clinical trial

Ultrasound-guided paravertebral nerve block anesthesia for percutaneous endoscopic laser unroofing treatment of symptomatic simple renal cysts-An innovative ambulatory surgery mode

Objective

This study was designed to evaluate the feasibility, efficacy, and safety of percutaneous ureteroscopy laser unroofing as an ambulatory surgery for symptomatic simple renal cysts under multilevel paravertebral nerve block anesthesia.

Methods

From December 2015 to September 2017, 33 simple renal cyst patients who had surgical indications were enrolled. Under ultrasound guidance, the T10/T11, T11/T12, and T12/L1 paravertebral spaces were identified, and 7-10 mL 0.5% ropivacaine was injected at each segment. Then a puncture needle was placed inside the cyst cavity under ultrasonic monitoring. A guidewire was introduced followed by sequential dilation up to 28/30 Fr. The extra parenchymal portion of the cyst wall was dissociated and incised using a thulium laser, and a pathological examination was performed.

Results

Sensory loss to pinprick from T8 to L1 and sensory loss to ice from T6 to L2 were observed in all patients. None of the patients complained of pain during surgery. No serious complications occurred perioperatively. After the surgery, all patients recovered their lower limb muscle strength quickly, got out of bed, resumed oral feeding, and left the hospital within 24 h of admission. The pathologic diagnosis of all cyst walls was a simple renal cyst. The mean follow-up was 35.8 months. At the end of follow-up, the cyst units were reduced in size by more than 50% compared to the preoperative size, and no patient experienced a recurrence.

Conclusion

Multi-level paravertebral nerve block for percutaneous ureteroscopy laser unroofing as an ambulatory surgery mode is feasible, safe, and effective for the treatment of simple renal cysts in selected patients.

Comparative Study Between Conventional Landmark Versus Ultrasound-Guided Paravertebral Block in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Study

INTRODUCTION

Thoracic paravertebral block (TPVB) has emerged as an effective and safe regional technique for providing postoperative analgesia. We aimed to compare the ease and efficacy of conventional landmark and ultrasound-guided (USG) paravertebral blocks for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

METHODS

This was a randomized controlled study. Seventy-six patients of either sex, age 18-40 years, body mass index (BMI) 18-29 kg/m², American Society of Anesthesiologists physical status classifications I and II posted for elective laparoscopic cholecystectomy under general anesthesia were randomly allocated into two groups of 38 each. Patients in group A were administered a paravertebral block using the anatomical landmark technique (ALT), and group B using an ultrasound-guided paravertebral block in the sitting position. In both groups, 20 ml of 0.5% bupivacaine injection was administered at the T7 vertebral level on the right side. The primary outcome was the first-pass success rate. Secondary outcomes were the number of passes and attempts, duration of analgesia, visual analog scale (VAS) score for pain during 24 h postoperatively and complications if any, were recorded.

RESULTS

No patients were excluded in the study. Demographic characteristics were comparable in both groups. The number of passes was less in group B (1.45±0.5) compared to group A (2.42±0.95) and was reported to be statistically significant (p = 0.001). The number of attempts was less in group B (1.00±0) as compared to group A (1.29±0.46) and was statistically significant (p = 0.001). The duration of analgesia was longer in group B (530.00±326.33 minutes) compared to group A (345.60±252.95 minutes) and was observed to be statistically significant (p<0.05). The VAS score was significantly lower in group B (1.87±0.78, 2.24 ±0.82) compared to group A (2.42±0.72, 3.13±1.07) at the second and fourth hours, respectively (p = 0.001).  Conclusion: We concluded that paravertebral block using an ultrasound-guided technique is more efficacious than the conventional landmark technique for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

Efficiency and safety of quadratus lumborum block in percutaneous nephrolithotomy: a meta-analysis of randomized controlled studies

To evaluate the effect of quadratus lumborum block (QLB) for postoperative analgesia after percutaneous nephrolithotomy (PCNL), we searched Pubmed, Embase, Cochrane library, the Chinese Biomedical Literature Database, and randomized controlled trials (RCTs) assessing analgesic efficacy of QLB for PCNL are included in this meta-analysis. The related trials met the inclusion criteria were analyzed using RevMan 5.4 software, the weighted mean difference (WMD), with their corresponding 95% CI, was calculated to compare continuous variables. Nine RCTs are included in the meta-analysis showed that QLB group had significantly lower opioids consumption (WMD - 29.59 95% CI - 43.64 to - 15.55; P < 0.00001), lessen visual analog scale (VAS) after surgery 2 h (WMD - 1.35, 95% CI - 1.93 to - 0.76; P < 0.00001), 6 h (WMD - 1.47, 95% CI - 2.04 to - 0.91; P < 0.00001) 12 h (WMD - 1.75, 95% CI - 3.17 to - 0.32; P = 0.02) and 24 h (WMD - 1.4, 95% CI - 1.86 to - 0.94; P < 0.00001), shorter hospital stay(WMD - 0.7, 95% CI -1.26 to - 0.14, P < 0.00001) and reduce intestinal exhaust recovery time (WMD - 7.41, 95% CI - 9.36 to - 5.46, P < 0.00001) than in the control group. QLB offers some potential advantages in terms of opioids consumption, VAS, hospital stay and intestinal exhaust recovery time. However, good quality and large studies with long-term follow-up are warranted for further research.

Effect of pregabalin on postoperative pain and instrumentation-induced dysuria in patients undergoing percutaneous nephrolithotomy: A prospective randomized, double-blinded placebo-controlled study

Background and Aims

The manipulation of urinary tract, the mandatory requirement of ureteral stenting, and bladder catheterization in patients undergoing percutaneous nephrolithotomy (PCNL) produces significant pain and dysuria postoperatively. The present study compared the efficacy of pregabalin with placebo in attenuation of these symptoms in patients undergoing PCNL.

Material and Methods

This randomized controlled study was conducted in 110 patients of either sex, aged 18-65 years undergoing elective PCNL requiring nephrostomy tube under general anesthesia. Group G (n: 53) received pregabalin 150 mg and Group P received placebo (n: 49) orally 1 h before the anesthetic induction. All the patients received standard anesthetic protocol. Pain at the site of nephrostomy, instrumentation-induced dysuria (IID), anxiety, and sedation scores were recorded at 0 min, 15 min, 30 min, 1 h, 2 h, 4 h, 8 h, 12 h, 24 h postoperatively. Hemodynamics, total requirement of rescue analgesia, and incidence of any adverse effects were also noted.

Results

Patients were demographically comparable between the two groups. There is no difference in nephrostomy site pain between the groups at different points of measurements. IID was less with pregabalin at 0 min, 15 min, 30 min, 1 h, and 2 h after extubation (P value < 0.05, 43% in Group G vs. 68% in group P). Severe urgency was seen in 4%, moderate in 31%, and mild in 33% of patients in placebo group. No patient in pregabalin had severe grade of instrumentation-induced dysuria score (P < 0.05). Patients in Group P required more rescue analgesic (P: 0.009). Anxiety scores, sedation scores, and hemodynamic parameters were comparable.

Conclusion

A single dose of 150 mg pregabalin as oral premedication given 1 h before surgery reduced the incidence and intensity of IID compared to placebo in patients undergoing PCNL without significant adverse effects.

The efficacy and safety of paravertebral block for postoperative analgesia in renal surgery: A systematic review and meta-analysis of randomized controlled trials

Background

Paravertebral block (PVB) has been widely used in postoperative analgesia, especially in thoracic and breast surgery. However, the efficacy and safety of PVB for analgesia after renal surgery remains uncertain. Therefore, this study aimed to determine the postoperative analgesic efficacy and safety of PVB in renal surgery.

Methods

PubMed, Web of Science, Embase, and the Cochrane Library databases were systematically searched up to December 20, 2021. All randomized controlled trials (RCTs) evaluating the postoperative analgesic efficacy of PVB in renal surgery were collected. The meta-analysis was performed using RevMan 5.4 and Stata/MP 14.0 software.

Results

A total of 16 RCTs involving 907 patients were included in the meta-analysis. Ten studies investigated patients under percutaneous nephrolithotomy (PCNL), and six studies were done for patients under other renal surgery (nephrectomy or pyeloplasty). Compared with control groups (no block, sham block, or other nerve blocks), meta-analysis showed that PVB reduced 24-hour postoperative opioid consumption significantly (SMD = −0.99, 95%CI: −1.60–0.38, p = 0.001, I² = 92%) and reduced pain scores at various time points within 24 h at rest and 1 h, 4 h, and 24 h at movement after renal surgery, furthermore, PVB prolonged the time to first postoperative analgesic requirement (SMD = 2.16, 95%CI: 0.94–3.39, p = 0.005, I² = 96%) and reduced the incidence of postoperative additional analgesia (OR = 0.14, 95%CI: 0.06∼0.33, p < 0.00001, I² = 50%). Subgroup analysis revealed that the postoperative analgesia effect of PVB was more significant in PCNL, and the use of bupivacaine for PVB seemed to have a better performance. Besides, there was no difference in the incidence of postoperative nausea, vomiting, and itching between PVB and control groups.

Conclusion

This study indicates that PVB may provide effective postoperative analgesia in patients under renal surgery, especially PCNL patients. Moreover, PVB is a safe analgesic method without significant analgesia-related complications.

Regional anesthesia techniques and postoperative delirium: systematic review and meta-analysis

INTRODUCTION

Postoperative delirium is a frequent occurrence in the elderly surgical population. As a comprehensive list of predictive factors remains unknown, an opioid-sparing approach incorporating regional anesthesia techniques has been suggested to decrease its incidence. Due to the lack of conclusive evidence on the topic, we conducted a systematic review and meta-analysis to investigate the potential impact of regional anesthesia and analgesia on postoperative delirium.

EVIDENCE ACQUISITION

PubMed, Embase, and the Cochrane central register of Controlled trials (CENTRAL) databases were searched for randomized trials comparing regional anesthesia or analgesia to systemic treatments in patients having any type of surgery. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We pooled the results separately for each of these two applications by random effects modelling. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and strength of conclusions.

EVIDENCE SYNTHESIS

Eighteen trials (3361 subjects) were included. Using regional techniques for surgical anesthesia failed to reduce the risk of postoperative delirium, with a relative risk (RR) of 1.21 (95% CI: 0.79 to 1.85); P=0.3800. In contrast, regional analgesia reduced the relative risk of perioperative delirium by a RR of 0.53 (95% CI: 0.42 to 0.68; P<0.0001), when compared to systemic analgesia. Post-hoc subgroup analysis for hip fracture surgery yielded similar findings.

CONCLUSIONS

These results show that postoperative delirium may be decreased when regional techniques are used in the postoperative period as an analgesic strategy. Intraoperative regional anesthesia alone may not decrease postoperative delirium since there are other factors that may influence this outcome.

Postoperative Pain Relief Following Lumbar Erector Spinae Plane Block in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Controlled Trial

OBJECTIVE

To test whether lumbar Erector Spinae Plane Block (ESPB) provides superior analgesia compared to placebo in patients undergoing Percutaneous Nephrolithotomy (PCNL), using reduction in postoperative opioid consumption, delay in rescue analgesia demand and reduction of pain scores as outcome measures.

METHODS

34 adult (18-60 years) ASA I and II patients undergoing unilateral PCNL were randomized into two groups (Bupivacaine and Saline) - both receiving ipsilateral ESPB at L1 vertebral level with either 20 ml 0.25% Inj. Bupivacaine or 20 ml normal saline respectively, at the start of the surgery under general anesthesia. The primary outcome measure was total 24-hour rescue opioid analgesic requirement, while time to first demand of rescue analgesic and pain scores at 2, 12 and 24 hours postoperatively were secondary outcomes.

RESULTS

The 24-hour requirement of rescue analgesic Tramadol was significantly lower (53.5 ± 29.6 vs 121.2 ± 51.1 mg) [mean ± SD] (P = .001) and time to first demand of rescue analgesia was more (14.1 ± 8.4 vs 6.0 ± 5.6 hours) [mean ± SD] (P = .001) in the Bupivacaine group as compared to placebo. The pain scores were significantly lower in the Bupivacaine group at 12-hour post-operatively [4 (3,4) vs 5.5 (5,6)] [median (IQR)] (P = .001), while the stone-load, surgical duration and intraoperative opioid use were comparable between the two groups and no block-related complications were noted in any patient.

CONCLUSION

Post-PCNL, ipsilateral lumbar ESPB reduced 24-hour opioid consumption and delayed time to demand for rescue analgesia as compared to placebo.

Opioid-sparing analgesic effects of peripheral nerve blocks in percutaneous nephrolithotomy: a systematic review

INTRODUCTION

Multimodal analgesia regimens incorporating peripheral nerve blocks (PNB) have demonstrated reduced postoperative pain, opioid use, and recovery time in various disease states. However, this remains a subject of limited investigation in the percutaneous nephrolithotomy (PCNL) domain. In the face of an ongoing opioid epidemic and collective push to enhance prescribing stewardship, we sought to examine the potential opioid-sparing effect of PNB in PCNL.

METHODS

A systematic review of Embase and PubMed was performed to identify all randomized controlled trials evaluating the use of a PNB with general anesthesia (GA) versus GA alone for pain control following PCNL. Studies evaluating neuraxial (epidural and spinal) anesthesia and those without GA as the control arm were excluded.

RESULTS

Seventeen trials evaluating 1012 procedures were included. Five different blocks were identified and evaluated: paravertebral (n=8), intercostal nerve (n=3), quadratus lumborum (n=2), transversus abdominis plane (n=1), and erector spinae (n=3). 9/16 (56%) studies observed lower pain scores with PNB use throughout the 24-hour postop period. By comparison, improved pain scores with PNB were limited to the early (<6 hours) recovery period in 5 studies and 2 found no difference. Total analgesia and opioid requirements were significantly higher in the GA control arm in nearly all studies (12/14, 86%). Operative times were similar and there were no differences in rates of intercostal access or nephrostomy tube insertion between study arms in any trial.

CONCLUSION

While greater analgesic use with GA alone likely minimizes or obscures differences in patient-reported pain scores, PNB may offer a significant opioid-sparing analgesic effect during postoperative recovery after PCNL.

Comparison of peritubal infiltration and single level T10 paravertebral block in percutaneous nephrolithotomy (PCNL)

Background and Aims:

Material and Methods:

Results:

Conclusion:

Analgesic efficacy of ultrasound guided paravertebral block in percutaneous nephrolithotomy patients: a randomized controlled clinical study

Background

Paravertabral blocks (PVB) are in use to adequately manage pain arising from a variety of operations on the thorax, abdomen or pelvis. PVB is straightforward, efficacious in operations performed. This study was undertaken to evaluate how efficacious ultrasound-guided thoracic paravertebral block is when used in patients undergoing percutaneous nephrolithotomy (PCN).

Methods

A total of 44 patients, falling in categories I to III of the American Society of Anesthesiologists, and aged between 18 and 65 years, who were scheduled for PCN, were randomly distributed into two groups. The anaesthetic intervention group (PVB) contained 22 individuals, who were injected at level T8-T9 with 20 mL 0.25% bupivacaine as a single administration. In the control group C, also containing 22 individuals, the intervention was not carried out. The groups were compared after PCN in terms of opioid use, pain score, opioid adverse effects profile and the need for supplemental analgesia.

Results

Visual analogue scale pain scores whilst at rest or moving were lower at the level of statistical significance in the PVB group compared to controls at 2 and 4 h post-surgery. At 6 and 8 h post-surgery, the control group had a lower VAS score when moving, and this result reached statistical significance (p < 0.05). The controls used more opioid relief than the PVB group and had lower scores for satisfaction (p < 0.05).

Conclusion

Ultrasound-guided PVB using bupivacaine and an in-plane technique provides effective analgesia in PNL. It is associated with high scores on patient satisfaction and minimal complications.

Trial registration

ClinicalTrials.gov, NCT04406012. Registered retrospectively, on 27 May 2020.

Postoperative analgesic efficacy of fluoroscopy-guided erector spinae plane block after percutaneous nephrolithotomy (PCNL): A randomized controlled study

Background:

Percutaneous nephrolithotomy (PCNL) a minimally invasive method for the removal of renal calculi and is associated with significant pain in postoperative period. Conventionally, intravenous opioids, local anesthetic infiltration, and regional blocks (intercostal/paravertebral blocks) have been tried with less efficacy to control postoperative pain. The present study is conducted to assess the effectiveness of erector spinae plane block (ESPB) performed under fluoroscopy guidance for postoperative analgesia during PCNL.

Subjects and Methods:

After obtaining ethical clearance, the study was conducted on 61 American Society of Anaesthesiologists (ASA) I and II patients aged between 18–65 years admitted for PCNL. Group I (n = 30) did not receive ESPB while Group II (n = 31) received ESPB under fluoroscopy guidance and 20 ml of 0.375% ropivacaine was administered after PCNL. Patient-reported pain intensity using visual analogue scale (VAS) was considered as a primary outcome. The hemodynamic variables (heart rate, systolic, diastolic, and mean blood pressure) was considered as a secondary outcome. Statistical analysis was performed using Student's t-test and Mann–Whitney U test. Data analysis was performed using the Statistical Package for the Social Sciences version 23.0.

Results:

Postoperatively VAS score was significantly lower in Group II at 0, 1, 2, 3, 4, 6, 12, 18, and 24 hours after PCNL (P < 0.001). Dose of rescue analgesia significantly decreased in Group II compared to Group I.

Conclusion:

ESPB performed under fluoroscopic guidance is a simple and effective technique and it provides significantly better postoperative pain relief.

The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy: A meta-analysis of randomized controlled studies

INTRODUCTION

The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy remains controversial. We conduct a systematic review and meta-analysis to explore the analgesic efficacy of paravertebral block for patients with percutaneous nephrolithotomy.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases, and randomized controlled trials (RCTs) assessing analgesic efficacy of paravertebral block for percutaneous nephrolithotomy are included in this meta-analysis.

RESULTS

Five RCTs are included in the meta-analysis. Overall, compared with control group after percutaneous nephrolithotomy, paravertebral block is associated with the decrease in analgesic consumption (standard mean difference (Std. MD) = -1.55; 95% confidence interval (CI) = -2.18 to -0.92; P < .00001) and additional analgesics (risk ratio (RR) = 0.17; 95% CI = 0.07 to 0.44; P = .0003), prolonged time to first analgesic requirement (Std. MD = 1.51; 95% CI = 0.26 to 2.76; P = .02). There is no statistical difference of adverse events including nausea or vomiting (RR = 0.51; 95% CI = 0.11 to 2.35; P = .38), or itching (RR = 0.69; 95% CI = 0.26 to 1.81; P = .45) between 2 groups.

CONCLUSIONS

Paravertebral block is effective for pain control after percutaneous nephrolithotomy.

Ultrasound-guided anterior quadratus lumborum block for postoperative pain after percutaneous nephrolithotomy: a randomized controlled trial

Background

The quadratus lumborum block (QLB), which is reported to provide analgesia to the abdominal region, is a newly defined fascial plane block method. The present study aimed to investigate the effect of ultrasound guided anterior QLB on the postoperative pain scores after percutaneous nephrolithotomy (PNL).

Methods

In this prospective, randomized, controlled single-blind study, 60 patients with elective PNL operations were randomized into 2 groups. In Group B (n = 30): anterior QLB+ intravenous patient-controlled analgesia (PCA) morphine and in Group C (n = 30): intravenous PCA morphine. Outcome measures were included for visual analog scale (VAS) scores and cumulated consumption for 24 hours postoperatively. Adverse effects, additional analgesic requirement, and intraoperative opioid requirement were recorded.

Results

The mean values of the quantity of cumulated morphine used at the 6th, 12th, and 24th hours were found to be statistically significantly lower in Group B (P < 0.05). The VAS scores were found to be statistically significantly lower in Group B (P < 0.05). There were no statistically significant differences in the rate of adverse effects, additional analgesic requirement, and intraoperative opioid requirement between the groups.

Conclusions

The study results suggest that anterior QLB is an effective treatment option for postoperative analgesia of PNL.

Effects of Ultrasound-Guided Thoracic Paravertebral Block on Postoperative Pain in Children Undergoing Percutaneous Nephrolithotomy

Objective

To compare the effects of ultrasound-guided thoracic paravertebral block (PVB) and intravenous paracetamol on postoperative pain control in paediatric patients undergoing percutaneous nephrolithotomy (PNL).

Methods

Forty patients aged 1-5 years, with an American Society of Anesthesiologists physical status I-II, scheduled for PNL were enrolled into this prospective randomised controlled trial. After arrival in the operating room, all patients were administered standardised general anaesthesia. Patients in Group PVB received ultrasound-guided PVB using bupivacaine 0.5% at a total volume of 0.5 mL kg^-1 at the vertebral levels T11, T12 and L1. Patients in Group P were administered paracetamol intravenously (15 mg kg^-1) before the beginning of surgery. Patients in both groups were given tramadol (1 mg kg^-1) for supplemental analgesia. Patient demographics, haemodynamic parameters, peripheral oxygen saturation and sevoflurane concentration were recorded. The Face, Legs, Activity, Cry and Consolability pain scores; satisfaction of parents; the number of patients requiring supplemental analgesia; and complications were evaluated during the postoperative period.

Results

Pain scores were significantly lower in Group PVB compared with Group P (p=0.001). There were no analgesic requirements in Group PVB; however, all patients needed a supplemental analgesic in Group P. Parental satisfaction was higher in Group PVB than in Group P.

Conclusion

This study demonstrated that ultrasound-guided PVB provides more effective postoperative analgesia with no side effects compared to intravenous paracetamol in children undergoing PNL.

Transmuscular quadratus lumborum block for percutaneous nephrolithotomy reduces opioid consumption and speeds ambulation and discharge from hospital: a single centre randomised controlled trial

BACKGROUND

Percutaneous nephrolithotomy (PNL) is associated with severe postoperative pain. The current study aimed to investigate the analgesic efficacy of transmuscular quadratus lumborum (TQL) block for patients undergoing PNL surgery.

METHODS

Sixty patients were enrolled in this single centre study. The multimodal analgesic regime consisted of oral paracetamol 1 g and i.v. dexamethasone 4 mg before surgery and i.v. sufentanil 0.25 μg kg^-1 30 min before emergence. After operation, patients received paracetamol 1 g regularly at 6 h intervals. Subjects were allocated to receive a preoperative TQL block with either ropivacaine 0.75%, 30 ml (intervention) or saline 30 ml (control). Primary outcome was oral morphine equivalent (OME) consumption 0-6 h after surgery. Secondary outcomes were OME consumption up to 24 h, pain scores, time to first opioid, time to first ambulation, and hospital length of stay. Results were reported as mean (standard deviation) or median (inter-quartile range).

RESULTS

Morphine consumption was lower in the intervention group at 6 h after surgery (7.2 [8.7] vs 90.6 [69.9] mg OME, P<0.001) and at 24 h (54.0 [36.7] vs 126.2 [85.5] mg OME, P<0.001). Time to first opioid use was prolonged in the intervention group (678 [285-1020] vs 36 [19-55] min, P<0.0001). Both the time to ambulation (302 [238-475] vs 595 [345-925] min, P<0.004) and length of stay (2.0 [0.8] vs 3.0 [1.2] days, P≤0.001) were shorter in the intervention group.

CONCLUSIONS

This is the first blinded, RCT that confirms that unilateral TQL block reduces postoperative opioid consumption and hospital length of stay. Further study is required for confirmation and dose optimisation.

CLINICAL TRIAL REGISTRATION

NCT02818140.

Peritubal Infiltration of Fentanyl Compared to Dexmedetomidine with Ropivacaine in Percutaneous Nephrolithotomy: A Randomized Comparative Analysis

Context:

Dexmedetomidine has been found as an effective adjuvant in various nerve blocks. Despite several studies on dexmedetomidine with ropivacaine, there is no study on comparing with fentanyl in peritubal infiltration in percutaneous nephrolithotomy (PCNL).

Aims:

The aim of this study was to compare the effect of the addition of dexmedetomidine or fentanyl in peritubal local anesthetic infiltration on pain scores and analgesic consumption in patients who underwent PCNL.

Settings and Design:

This was a prospective, randomized, double-blind, tertiary care center-based study.

Subjects and Methods:

A total of 60 American Society of Anesthesiologists Class I, II, and III patients were selected and randomly divided into two groups: Group RF ropivacaine and fentanyl (n = 30) and Group RD ropivacaine and dexmedetomidine (n = 30). Balanced general anesthesia was given. After completion of the surgery, peritubal infiltration was given at 6 and 12 O’clock positions under fluoroscopic guidance. Postoperative pain was assessed using the visual analog scale and dynamic visual analog scale rating 0–10 for initial 48 h. Postoperative sedation was assessed using five-point sedation score. Time to first rescue analgesic, number of doses of tramadol, and total consumption of tramadol required in 48 h were noted.

Statistical Analysis Used:

Descriptive data were expressed in mean and standard deviation for between-group comparisons; the Chi-square and Fisher's exact tests were used for categorical variables, whereas t-test and Mann–Whitney U-test were used to compare continuous variables between two groups.

Results:

Duration of analgesia in group RD (12.87 ± 3.85) is more prolonged than group RF (8.13 ± 3.28) h. Total dose of rescue analgesia required in 48 h in group RF was higher as compared to group RD.

Conclusions:

Addition of dexmedetomidine to ropivacaine is more effective than fentanyl in terms of prolongation of analgesic efficacy of local anesthetic in peritubal block along with short-lived mild sedation.

Thoracic paravertebral block for postoperative pain management after renal surgery: A randomised controlled trial

BACKGROUND

Thoracic paravertebral block (ThPVB) combined with general anaesthesia is used in thoracic and general surgery. It provides effective analgesia, reduces surgical stress response and the incidence of chronic postoperative pain.

OBJECTIVE

To assess the efficacy of ThPVB in reducing opioid requirements and decreasing the intensity of pain after renal surgery.

DESIGN

A randomised, open label study.

SETTING

A single university hospital. Study conducted from August 2013 to February 2014.

PARTICIPANTS

In total, 68 patients scheduled for elective renal surgery (open nephrectomy or open nephron-sparing surgery).

INTERVENTIONS

Preoperative ThPVB with 0.5% bupivacaine combined with general anaesthesia, followed by postoperative oxycodone combined with nonopioid analgesics as rescue drugs. Follow-up period: 48 h.

MAIN OUTCOME MEASURES

Total dose of postoperative oxycodone required, pain intensity, occurrence of opioid related adverse events, ThPVB-related adverse events and patient satisfaction.

RESULTS

A total of 68 patients were randomised into two groups and, of these, 10 were subsequently excluded from analysis. Patients in group paravertebral block (PVB; n = 27) had general anaesthesia and ThPVB, and those in group general (anaesthesia) (GEN) (n = 31) formed a control group receiving general anaesthesia only. Compared with patients in group GEN, patients who received ThPVB required 39% less i.v. oxycodone over the first 48 h and had less pain at rest (P < 0.01) throughout the first 24 h. Group PVB patients also experienced fewer opioid-related adverse events and were less sedated during the first 12 postoperative hours. Patients in the PVB group had higher satisfaction scores at 48 h compared with the control group. There were no serious adverse events.

CONCLUSION

In our study, preoperative ThPVB was an effective part of a multimodal analgesia regimen for reducing opioid consumption and pain intensity. Methods and drugs used in both groups were well tolerated with no serious adverse events. Compared with the control group, patients in the ThPVB group reported increased satisfaction.

TRIAL REGISTRATION

Clinical Trials NCT02840526.

Quadratus Lumborum Block III for Postoperative Pain After Percutaneous Nephrolithotomy

Objective

An effective pain control is important in early mobilization and returning to normal daily life following percutaneous nephrolithotomy (PCNL) operations. The use of an intraoperative local anaesthetic or postoperative analgesic has been reported for pain control in PCNL. Transmuscular quadratus block (QLB III) is a regional anaesthetic technique applied under ultrasound guidance. The aim of this study was to investigate the effectiveness of QLB III on postoperative pain in PCNL.

Methods

This prospective, randomized, double-blinded study was carried out at the Dr Ersin Arslan Training and Research Hospital between December 2016 and March 2017. The QLB III block was administered to a total of 44 patients who had undergone elective PCNL under spinal anaesthesia. While half of the patients (Group S, n=22) received 0.2 cc kg^-1 of 0.9% saline, the other half (Group Q, n=22) received 0.2 mL kg^-1 of 0.0125 isobaric bupivacain with QLB III. For all patients, the pain level was measured using the visual analog scale (VAS), and the morphine consumptions through patient-controlled analgesia (PCA) were recorded at the postoperative 4, 8, 12, 24, and 48 hours.

Results

The postoperative VAS was found to be statistically significantly higher at the 8^th, 12^th, and 24^th hour in Group S (p<0.05). The postoperative morphine consumption was determined to be statistically significantly higher at the 4^th, 8^th, 12^th, and 24^th hour in Group S (p<0.05).

Conclusion

The QLB III was observed to be effective in pain control and reducing morphine consumption during the postoperative 48 hours follow-up after PCNL.

Comparative study of ultrasound-guided paravertebral block versus intravenous tramadol for postoperative pain control in percutaneous nephrolithotomy

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is a minimally invasive surgical procedure for renal calculi, and nephrostomy tubes lead to postoperative pain after PCNL. Regional techniques (e.g., epidural analgesia and peripheral blocks) and opioids are applied for postoperative pain treatment. The aim of this study was to compare effectiveness of ultrasound-guided paravertebral block (PVB) and tramadol on postoperative pain in patients who underwent PCNL.

METHOD

Fifty-three patients were included in this prospective randomized study. The patients were allocated into two groups: the PVB group (group P, n = 26) and the tramadol group (group T, n = 27). All patients were administered standard general anaesthesia. Ultrasound-guided PVB was performed at the T11- L1 levels using 0.5% bupivacaine for a total dose of 15 mL in group P. Patients in group T were intravenously administered a loading dose of 1 mg/kg tramadol. Patients in both groups were given patient-controlled analgesia. Haemodynamic parameters, visual analogue scale (VAS) scores, side effects, and complications, tramadol consumption and additional analgesic requirements of the patients were recorded after surgery.

RESULTS

Haemodynamic parameters were statistically similar between the groups. The VAS in group P were statistically lower than in group T. In the 24-h period after surgery, total PCA tramadol consumption was statistically lower in group P than in group T. The use of supplemental analgesic in group T was higher than in group P.

CONCLUSIONS

Ultrasound-guided PVB was found to be an effective analgesia compared to tramadol, and no additional complications were encountered.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02412930 , date of registration: March 27, 2015, retrospectively registered.

Efficacy of single-injection unilateral thoracic paravertebral block for post open cholecystectomy pain relief: a prospective randomized study at Gondar University Hospital

Background

Cholecystectomy can be associated with considerable postoperative pain. While the benefits of paravertebral block (PVB) on pain after thoracotomy and mastectomy have been demonstrated, not enough investigations on the effects of PVB on pain after open cholecystectomy have been conducted. We tested the hypothesis that a single-injection thoracic PVB reduces pain scores, decreases opioid consumption, and prolongs analgesic request time after cholecystectomy.

Methods

Of 52 patients recruited, 50 completed the study. They were randomly allocated into two groups: the paravertebral group and the control group. The outcome measures were the severity of pain measured on numeric pain rating scale, total opioid consumption, and first analgesic request time during the first postoperative 24 hours.

Result

The main outcomes recorded during 24 hours after surgery were Numerical Rating Scale (NRS) pain scores (NRS, 0–10), cumulative opioid consumption, and the first analgesic request time. Twenty four hours after surgery, NRS at rest was 4 (3–6) vs 5 (5–7) and at movement 4 (4–7) vs 6 (5–7.5) for the PVB and control groups, respectively. The difference between the groups over the whole observation period was statistically significant (P<0.05). Twenty-four hours after surgery, median (25th–75th percentile) cumulative morphine consumption was 0 (0–2) vs 2.5 (2–4) mg (P<0.0001) and cumulative tramadol consumption was 200 (150–250) mg vs 300 (200–350) mg in the paravertebral and in the control group, respectively (P=0.003). After surgery, the median (25th–75th percentile) first analgesic requirement time was prolonged in the PVB group in statistically significant fashion (P<0.0001).

Conclusion and recommendations

Single-shot thoracic PVB as a component of multi-modal analgesic regimen provided superior analgesia when compared with the control group up to 24 postoperative hours after cholecystectomy, and we recommend this block for post cholecystectomy pain relief.

The Effect of Peritubal Infiltration with Bupivacaine and Morphine on Postoperative Analgesia in Patients Undergoing Percutaneous Nephrolithotomy

Objective. We aimed to investigate the effect of peritubal local anesthetic and opioid infiltration on pain scores and analgesic consumption in patients who underwent percutaneous nephrolithotomy. Material and Methods. Patients aged between 18 and 65 years and ASA I-III were included in this double-blind, randomized study. The patients were divided into two groups. All patients underwent spinoepidural anesthesia. 20 mL of 0.25 percent bupivacaine + 5 mg morphine (0.5 mL), in Group P (n = 66), infiltrated the renal capsule, perinephric fat, muscles, subcutaneous tissue, and skin under fluoroscopy. In Group C (n = 64), none of the patients received a peritubal injection. In the first 24 h pain scores, time of the first analgesic demand, the mean number of analgesic demands, and postoperative complications were compared between groups. Results. The mean VAS score at postoperative 8, 12, and 24 h and dynamic VAS score at postoperative 4, 8, 12, and 24 h were significantly lower in Group P. VAS score at postoperative 4 h was not significant. Time of the first analgesic demand was significantly longer in Group P. Conclusion. Our study results suggest that peritubal infiltration of bupivacaine with morphine after percutaneous nephrolithotomy is an effective method for postoperative pain control and reduces analgesic consumption.

Paravertebral block for surgical anesthesia of percutaneous nephrolithotomy: Care-compliant 3 case reports

BACKGROUND

Paravertebral block is often used to provide postoperative analgesia after renal surgery. In this case-series report, we present our experience with 3 patients in whom percutaneous nephrolithotomy was performed successfully under ultrasound-guided 3-segment lumbar-thoracic paravertebral block.

CASE SUMMARY

Three patients were scheduled for percutaneous nephrolithotomy. All 3 patients were high-risk cases for both general and neuraxial anesthesia. After due deliberation and with the consent of patient and his family, ultrasound-guided paravertebral block was performed. Seven to 10 mL of 0.5% ropivacaine was injected at T10/T11, T11/T12, and T12/L1 paravertebral place, respectively. Sensory loss to pinprick from T8 to L2 was achieved in all 3 patients 20 min after administration of block. Surgical procedures for all 3 patients were successful, and none of the patients complained of pain during the operation.

CONCLUSIONS

Ultrasound-guided multilevel paravertebral block may be an attractive option for anesthetic management of percutaneous nephrolithotomy in clinical practice.

Lidocaine Skin Patch (Lidopat® 5%) Is Effective in the Treatment of Traumatic Rib Fractures: A Prospective Double-Blinded and Vehicle-Controlled Study

OBJECTIVE

The purpose of this study was to determine the efficacy of the Lidopat(®) 5% skin patch in relieving rib fracture pain.

SUBJECTS AND METHODS

From June 2009 to May 2011, 44 trauma patients with isolated rib fractures were enrolled in this study and randomized in a double-blind method into 2 groups. The experimental group (group E: 27 patients) used a Lidopat(®) 5% skin patch at the trauma site and took an oral analgesic drug for pain relief. The placebo group (group P: 17 patients) used a placebo vehicle patch and an oral analgesic drug.

RESULTS

The mean age, weight and hospital stay of patients were 56.8 ± 13.8 years, 67.4 ± 12.6 kg and 6.34 ± 1.3 days, respectively. In the first 4 days, there were no significant differences in pain scores between the groups (p > 0.05). After the 5th day, the average pain score was significantly less in group E (mean 1.5) than in group P (mean 3.10; p < 0.05). There was no significant difference in the number of fractured ribs between groups (p = 0.904). The use of meperidine and the length of hospital stay (6.0 vs. 6.9 days) were both significantly less in group E (p = 0.043 and 0.009, respectively).

CONCLUSION

In this study, the use of the Lidopat(®) 5% skin patch in patients with isolated rib fractures alleviated pain and shortened the hospital stay, and a lower dose of pain-relieving medication was used.

Thoracic Paravertebral Block versus Epidural Anesthesia Combined with Moderate Sedation for Percutaneous Nephrolithotomy

OBJECTIVE

To investigate the feasibility of thoracic paravertebral block (TPVB) for percutaneous nephrolithotomy (PCNL) in comparison with epidural anesthesia (EA) combined with moderate sedation.

SUBJECTS AND METHODS

One hundred American Society of Anesthesiologists (ASA) I-II adult patients scheduled for first-stage unilateral PCNL were randomly assigned to receive either TPVB or EA. All patients were given standard sedation and analgesia with propofol and sufentanil. Patient characteristics, surgical outcomes, anesthetic outcomes, and time to first use of a patient-controlled intravenous analgesic (PCIA) device and postoperative consumption of sufentanil in the first 24 h were recorded. Intergroup differences of the parameters were analyzed using an independent t test, Mann-Whitney test, and χ2 test as appropriate.

RESULTS

Patients who received TPVB consumed more propofol during ureteroscopy (56.2 ± 28.4 vs. 42.9 ± 27.5 mg, p < 0.05) and more sufentanil during ureteroscopy (9.7 ± 4.8 vs. 3.9 ± 2.7 μg, p < 0.05) and during PCNL (7.0 ± 4.3 vs. 1.9 ± 1.8 μg, p < 0.05) than those who received EA. The volume fluids infused in patients who received TPVB was less than in those who received EA (854 ± 362 vs. 1,320 ± 468 ml, p < 0.05). Time to first PCIA use, postoperative 24-hour consumption of sufentanil, and other parameters were comparable between groups.

CONCLUSIONS

In this study, TPVB was as effective and safe as EA in providing intraoperative anesthesia and postoperative analgesia for PCNL, although more sedatives and analgesics were used during PCNL in patients who received TPVB.

Minimally invasive surgical treatment for kidney stone disease

Minimally invasive interventions for stone disease in the United States are mainly founded on 3 surgical procedures: extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy. With the advancement of technology, treatment has shifted toward less invasive strategies and away from open or laparoscopic surgery. The treatment chosen for a patient with stones is based on the stone and patient characteristics. Each of the minimally invasive techniques uses an imaging source, either fluoroscopy or ultrasound, to localize the stone and an energy source to fragment the stone. Extracorporeal shock wave lithotripsy uses a shock wave energy source generated outside the body to fragment the stone. In contrast, with ureteroscopy, laser energy is placed directly on the stone using a ureteroscope that visualizes the stone. Percutaneous nephrolithotomy requires dilation of a tract through the back into the renal pelvis so that instruments can be inserted directly onto the stone to fragment or pulverize it. The success of the surgical intervention relies on performing the least invasive technique with the highest success of stone removal.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

[Adding 75 mg pregabalin to analgesic regimen reduces pain scores and opioid consumption in adults following percutaneous nephrolithotomy]

BACKGROUND AND OBJECTIVES

Adding novel adjunctive drugs like gabapentinoids to multimodal analgesic regimen might be reasonable for lessening postoperative pain scores, total opioid consumption and side effects after percutaneous nephrolithotomy. We aimed to evaluate the effect of pregabalin on postoperative pain scores, analgesic consumption and renal functions expressed by creatinine clearance (CrCl) and blood neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (Cys C) levels in patients undergoing percutaneous nephrolithotomy (PCNL).

METHODS

60 patients undergoing elective PCNL were enrolled in the study. Patients were randomized to oral single dose 75 mg pregabalin group and a control group. Visual Analog Scale pain scores (VAS), postoperative intravenous morphine consumption during the first 24 postoperative hours, serum NGAL, Cys C levels and creatinine clearance (CrCl) was measured preoperatively and post-operatively at 2nd and 24th hour.

RESULTS

Postoperative VAS scores were significantly decreased in the pregabalin group at the postoperative 30th min, 1st, and 2nd hour (p = 0.002, p = 0.001 and p = 0.027, respectively). Postoperative mean morphine consumption was statistically significantly decreased for all time intervals in the pregabalin group (p = 0.002, p = 0.001, p = 0.001, p = 0.001, p < 0.001, respectively). No statistically significant differences were found between the two groups with regard to CrCl, or Cys C at preoperative and postoperative 2nd and 24th hour. Postoperative 24th hour NGAL levels were significantly decreased in the pregabalin group (p = 0.027).

CONCLUSIONS

Oral single-dose preemptive 75 mg pregabalin was effective in reducing early postoperative pain scores and total analgesic consumption in patients undergoing PCNL without leading to hemodynamic instability and side effects.