Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page) Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less) Background and Aims Ultrasound-guided Interscalene brachial plexus block is typically administered to patients undergoing surgery in the upper limbs. Recently, extrafascial injection has been introduced; however, its efficacy and safety remain debatable. This systematic review meta-analysis (PROSPERO: CRD42023426498) sought to compare extrafascial and intrafascial injections. Methods We systematically searched six electronic databases for randomised clinical trials comparing extrafascial and intrafascial injections for interscalene brachial plexus block. A random-effects model calculated risk ratio or mean differences (MD) with a 95% confidence interval (CI). The Cochrane Risk of Bias tool was used to assess the risk of bias. Results Six studies, a total of 485 patients, met our criteria. The risk of bias in four studies was low, with some concerns in two. The incidence of hemidiaphragmatic paresis was less in the extrafascial injection: [RR 3.01; 95% CI (2.13, 4.25); P < 0.00001]. There was a significantly higher incidence of complications in intrafascial compared to the extrafascial group for paraesthesia and hoarseness; RR 7.39; 95% CI (1.88, 29.07); P = 0.004] and [RR 3.88; 95% CI (0.99, 15.19); P = 0.05], respectively. Onsets of motor and sensory block were rapid in the intrafascial group: [MD -5.48; 95% CI (-8.85, -2.11); P = 0.001] and [MD -5.01; 95% CI (-8.49, -1.54); P = 0.005], respectively. The duration of sensory block was not significantly different between both groups: [MD 17.92; 95% CI (-38.15, 74.00); P = 0.53]. Conclusions Extrafascial injection effectively reduces block-related complications such as hemidiaphragmatic paresis and is associated with preserving respiratory parameters such as forced vital Capacity.
Please confirm that an ethics committee approval has been applied for or granted: Yes: I'm uploading the Ethics Committee Approval as a PDF file with this abstract submission Application for ESRA Abstract Prizes: : I apply as an Anesthesiologist (Aged 35 years old or less) Background and Aims The purpose of this study was to evaluate the relationship between remifentanil-induced hyperalgesia(RIH) and p21 activated kinase4(PAK4) in the spinal dorsal horn of rats with incisional pain. Methods Sprague-Dawley rats weighing 280-300g aged 9-11 weeks were divided into four groups (n = 12 each): control group(C), incisional pain group(I), incisional pain+remifentanil group(IR), incisional pain+remifentanil+PAK4 inhibitor group(IRP). Groups I and C received intravenous saline, while Group IR and IRP received intravenous remifentanil at dose of 1.2 μg·kg-1·min-1 for 90 minutes. PAK4 inhibitor PF3758309 10 nmol was intrathecally injected 30 minutes before surgery and once daily for five days after incision in group IRP, while the same intrathecal injection with DMSO in the other groups. The paw mechanical withdrawal threshold (PMWT) was measured respectively at 30 min before surgery and at 2 hours, 1 to 5 days after surgery. NLRP3 in spinal dorsal horn was detected by Western Blot. Results PMWT decreased at 2 hours after surgery in the incisional side. PMWT of healthy foot only decreased in group I and IR at 2 hours after surgery. Compared with group IR, PMWT increased in group IRP at 3 days after surgery in incisional side, while at 2 hours in healthy side. This study indicates that PF3758309 could cut off the formation of RIH since 2 hours after surgery by modulating NLRP3 inflammasome activation conducted by PAK4 in spinal dorsal horn. Conclusions PAK4 inhibitor could be effective to decrease the development and maintenance of RIH and increase pain threshold in rats.
Please confirm that an ethics committee approval has been applied for or granted: Yes: I’m uploading the Ethics Committee Approval as a PDF file with this abstract submission Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less) Background and Aims The Dural Puncture Epidural (DPE) seems to provide better sacral labor analgesia than the conventional Epidural (EPL) technique when performed with 25 and 26-G spinal needles. This double-blinded randomized controlled trial aims to investigate whether a 27-G needle DPE results in faster bilateral sacral blockade compared to EPL. Methods Following ethics approval and written consent, 108 nulliparous women were included. 54 patients received a conventional EPL, while the DPE group (n=54) received a needle-through-needle dural puncture technique using a 27-G Whitacre needle. In both groups analgesia was initiated epidurally with 15 mL of ropivacaine 0.1% and sufentanil 0.5 mcg mL–1 and maintained with 10 ml bolus of the same mixture provided hourly through a Programmed Intermittent Epidural Bolus infusion. Bilateral sacral blockade was tested at the S2 dermatomes using a pin-prick examination 10 minutes after analgesia completion, then at pre-defined intervals until delivery. Results Time to bilateral sacral blockade was significantly different in the two groups (hazard ratio 0.30, 95% confidence interval [CI] 0.19 to 0.48, P<0.001). One hour after analgesia initiation 94% DPE patients achieved bilateral sacral blockade compared to 63% of the EPL group (P <0.001), with greater results at 10 minutes (risk ratio [RR] 3.00, 95% CI 1.69 to 5.29; P<0.001) and at 20 minutes (RR 2.38, 95% CI 1.35 to 4.21; P=0.001). Conclusions Within 1 hour after initiation of neuraxial analgesia, the DPE technique using a 27-G Whitacre spinal needle provides an improved S2 dermatomes coverage compared to EPL.
BACKGROUND:Haemorrhoidectomy is associated with moderate-to-severe postoperative pain. OBJECTIVE:The aim of this systematic review was to assess the available literature and update previous PROSPECT (procedure specific postoperative pain management) recommendations for optimal pain management after haemorrhoidectomy. DESIGN AND ELIGIBILITY CRITERIA:A systematic review utilising PROSPECT methodology was undertaken. DATA SOURCES:Randomised controlled trials published in the English language from January 1, 2016 to February 2, 2022 assessing postoperative pain using analgesic, anaesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Database. RESULTS:Of the 371 randomized controlled trials (RCTs) identified, 84 RCTs and 19 systematic reviews, meta-analyses met our inclusion criteria (103 publications). Interventions that improved postoperative pain relief included: paracetamol and nonsteroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors, systemic steroids, pudendal nerve block, topical metronidazole, topical diltiazem, topical sucralfate or topical glyceryl trinitrate, and intramuscular injection of botulinum toxin. DISCUSSION:This review has updated the previous recommendations written by our group. Important changes are abandoning oral metronidazole and recommending topical metronidazole, topical diltiazem, topical sucralfate, topical glyceryl trinitrate. Botulinum toxin can also be administered. Contemporary publications confirm the analgesic effect of bilateral pudendal nerve block but invalidate recommendations on perianal infiltration. The choice of the surgery is mostly left to the discretion of the surgeons based on their experience, expertise, type of haemorrhoids, and risk of relapse. That said, excisional surgery is more painful than other procedures.
( Eur J Anaesthesiol . 2024;41(2):129–135. doi: 10.1097/EJA.0000000000001926) Preoperative fasting is commonly recommended to prevent the risk of pulmonary aspiration of gastric contents during anesthesia. The European Society of Anaesthesiology and Intensive Care (ESAIC) advises fasting for 6 hours for solids and 2 hours for liquids prior to surgery (eg, caesarean delivery, CD). However, a long fasting period can impart both maternal and neonatal risk. As such, the liberal drinking “Sip Til Send” protocol has been widely used in the United Kingdom and Ireland with no associated pulmonary aspiration cases reported. This study aimed to assess residual gastric volumes in nonlaboring parturients presenting for elective CD and compare volumes in fasted patients to volumes after the same patients were allowed liberal oral hydration. The authors hypothesized there would be no significant difference in gastric volumes.
Please confirm that an ethics committee approval has been applied for or granted: Yes: I’m uploading the Ethics Committee Approval as a PDF file with this abstract submission Application for ESRA Abstract Prizes: I apply as a Trainee/Resident/Fellow (no age limit) Background and Aims Effective analgesia after CS is essential to enhance recovery. Recent PROSPECT guidelines highlighted the importance of multimodal analgesia including paracetamol, NSAIDs, regional anesthesia and IV Dexamethasone.1 Usually, doses of Dexamethasone are 0.2mg/kg) seem to generate analgesic superiority.2,3 This randomized, double-blind study aimed to compare HIGH- versus LOW-dose Dexamethasone for post-CS analgesia. Methods Following ethical approval and informed consent, 210 patients undergoing CS were randomized to 5mg or 2x25mg of IV-Dexamethasone. Multimodal analgesia was given in both groups including paracetamol, NSAIDs, wound infiltration and bilateral ilio-inguinal nerve block. Opioids were given as rescue. In the LOW-group 5mg IV-Dexamethasone was given after delivery. In the HIGH-group 25mg IV-Dexamethasone was given after delivery and 24hours later. Primary endpoint was the cumulated NRS-pain scores at movement 4-48 hours after CS quantified as area under the curve (AUC). Secondary endpoints included pain scores at rest, patient satisfaction, rescue analgesics, side-effects and functional recovery. Results In the HIGH-group the hourly AUC pain score at movement was significantly reduced by 15% from 3.11±1.14 to 2.65±1.25 (p=0.0011), and pain scores at rest and highest pain scores were lower. Less patients required rescue opioids (75% vs 58%, p=0.011), morphine consumption was reduced (9.1 to 5.2mg, p=0.0003) and functional recovery improved. Glycemia and wound healing were normal in both groups. Conclusions Compared to a single 5mg dose of Dexamethasone, 2 x 25mg Dexamethasone added to multimodal analgesia provided superior analgesia with lower opioid consumption without an increase in side-effects. References Roofthooftetal. Anaesthesia. 2021;76: 665–680. Lunnetal. Brit J Anaesth. 2011;106: 230–238. VandeVeldeMetal. Eur J Anaesthesiol. 2023;40: 151–152.
Abstract BACKGROUND:Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the knee (IPACK) and the adductor canal block (ACB), are promising analgesic pathways but supporting literature remains rare. Periarticular injections (PAIs) are becoming an essential multimodal joint analgesia. We hypothesized that ACB and IPACK would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone.METHODS:This double-blinded randomized controlled trial included 50 patients undergoing ACL repair. Patients either received (1) a PAI (control group, n = 26) or (2) an iPACK with an ACB (intervention group, n = 24). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption.RESULTS:The intervention group reported significantly lower pain scores on ambulation than the control group on POD 1 (difference in means [95% confidence interval]; P < .001). In addition, pain scores on ambulation on POD 2 for group B (3.5 [-4.3 to -2.7]) and POD 2 for group A (1.0 [1.9 to 0.1]; with P = .033) were significantly lower. Patients in the intervention group were more satisfied, had less intravenous opioid consumption (post anesthesia care unit, P = .028), and reduced need for intravenous patient-controlled analgesia for the first 24 hours (P = .037).CONCLUSIONS:The addition of iPACK and ACB significantly improves analgesia and reduces opioid consumption after ACL repair compared to PAI alone. This study strongly supports iPACK and ACB use within a multimodal analgesic pathway.
Objective: Several interfascial interfacial plane blocks have been described in patients undergoing modified radical mastectomy. We conducted this study to evaluate the analgesic efficacy of ultrasound-guided serratus anterior plane block and erector spinae plane block in patients undergoing modified radical mastectomy. Methods: Totally, 80 female patients (18-70 years) undergoing modified radical mastectomy were randomised into 2 groups of 40 each and were given ultrasound-guided serratus anterior plane block or erector spinae plane block with 0.4 mL kg(-1) of 0.375% ropivacaine in this prospective double-blind control trial. The groups were compared for the time to request of first dose of rescue analgesic, requirement of rescue analgesics, and patient satisfaction score. Results: The time to request of the first rescue analgesia was comparable in both groups (P =.056). Postoperative pain scores at rest at 0 minute were significantly lower in serratus anterior plane group as compared to erector spinae plane group (P =.03). The intraoperative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable between the 2 groups. The number of patients requiring rescue doses of fentanyl intraoperatively and rescue analgesics postoperatively was similar in both groups. The mean patient satisfaction score was also comparable in both groups. Conclusion: Ultrasound-guided serratus anterior plane block and erector spinae plane block have comparable postoperative analgesic efficacy after modified radical mastectomy.
Background and Aims Maintenance of neuraxial labour analgesia using programmed intermittent epidural boluses (PIEB) is superior compared to continuous epidural infusions with/without patient controlled epidural analgesia (PCEA), causing less breakthrough pain, motor block and local anesthetic (LA) consumption1. Compared to low-volume PCEA without background infusion, PIEB produces less breakthrough pain and motor block, despite higher LA consumption. The goal of this randomised, double-blind, non-inferiority study was to investigate if high-volume PCEA without background infusion compared to PIEB+PCEA, set with equal boluses, results in a similar incidence of breakthrough pain and LA consumption. Methods Following ethics approval and written consent, combined spinal-epidural for labour was performed in 360 nulliparous women. Analgesia was maintained with ropivacaine 0.12% and sufentanil 0.75mcg/mL. Patients randomly received high-volume PCEA without background infusion set at 10 mL bolus with a 30 min lock-out or PIEB as 10 mL bolus every hour plus PCEA boluses of 5 mL with a 30 min lock-out. Breakthrough pain, motor block and LA consumption were recorded. Results Final analysis was performed in 336 women (PCEA n=170; PIEB-PCEA n=166). Breakthrough pain occurred in 11.2% in the PCEA-group and 10.8% in the PIEB-group. Total LA consumption was lower in the PCEA-group than in the PIEB-group (mean 53.1 versus 65.2 mL respectively, p< 0.0001). Motor block was not different between groups (p=0.783). Conclusions High-volume PCEA without background infusion and PIEB showed a similar incidence of breakthrough pain and motor block. The PCEA-group had a lower total LA consumption.
Background and Aims Modulation of mRNA expression ofOXTRgene following the use of ultrasound-guided transversals fascia plane block when compared with wound infiltration for post-cesarean pain management for prevention of chronic persistent post-surgical pain (CPSP). Methods The present randomized, controlled study was conducted following IEC- Human approval, prospective CTRI registration and written informed consent from participants. All patients of ASA-I and I undergoing cesarean delivery(CD) under SAB were included. Patients were randomized into two groups, patients in group C received standard wound infiltration using 20 ml of 0.375% ropivacaine and patients in group-T, received bilateral ultrasound-guided Transversalis fascia plane block using 20 ml of 0.375% ropivacaine at the end of the surgery. OXTR gene expression was done as per standard protocol from the samples withdrawn at baseline and at the end of 14th week. Un-paired student t-test, Mann-Whitney U test and Pearson correlation were used. Results Finally, 60 patients with 30 patients in each group were included. The mean delta Ct of OXTRgene expression at baseline was comparable between the two groups; however, upregulated in group T at 14’ week i.e. 2.41+0.72 vs 1.61+0.84. Similarly, the fold changes of OXTRgene expression in test group at the end of 14th week was higher i.e. 7.44 vs 4.35. A significant positive correlation was observed between theOXTR gene expression and pain intensity at 14th week. Conclusions A significant up-regulation ofOXTRgene and its significant positive correlation with pain intensity following TFPB validates the efficacy of TFPB for prevention of CPSP following cesarean delivery.
Background and Aims The medial femoral cutaneous nerve (MFCN) is known to innervate the anteromedial knee area.1,2 A selective block of the anterior branch from the MFCN (MFCN-A) but not the posterior branch (MFCN-P) has been described.3,4 We present an ultrasound-guided technique for blockade of the MFCN-P. Post-hoc analysis of data from a randomized, controlled trial showed that the MFCN-A or MFCN-P may innervate the distal part of the medial lower leg and even the medial malleolus (MM) which has never previously been described.4 We present a case of cutaneous neuropathy in the “classical saphenous nerve territory” on the medial side of the lower leg and MM, where a selective MFCN-P block was used for diagnosis and treatment of the neuropathic pain.5 Methods A woman presented with severe chronic neuropathic pain on the medial side of the lower leg and MM. The worst pain was localized to the MM. Diagnostic nerve blocks were performed in the following order: 1) SN; 2) MFCN-A; 3) MFCN-P (figure 1 and 2). Results The SN, MFCN-A and MFCN-P all innervated part of the skin in the neuropathic area. SN block alone marginally reduced NRS, whereas additional MFCN-A block did not further reduce NRS. MFCN-P block anesthetized the area around the MM and significantly reduced the pain. Perineural botox was injected around the SN and MFCN-P. At 2-weeks follow-up NRS was significantly reduced (table 1) and patient satisfaction high. Conclusions We present a novel selective MFCN-P block, which may be important in the diagnosis and treatment of chronic neuropathic pain.
Background and Aims Erector Spinae Plane Block (ESPB) can be applied at all vertebral levels and low thoracic applications are reported in abdominal surgeries. To our knowledge there exists no study of the pharmacokinetics of different local anesthetics in low thoracic ESPB. Here, we aimed to measure and determine the time-concentration relation of the plasma bupivacaine levels at different time points after low thoracic ESPB. Methods The observational pharmacokinetic study was performed between March 2021 and March 2022 after IRB approval. ASA class I-II patients aged between 18–65 y undergoing laparoscopic Nissen fundoplication were enrolled into the study. Patients who had paraspinal surgery or a history of previous abdominal surgery were excluded. At the end of the surgery, under general anesthesia, 20 mL of 0.25% bupivacaine was used consecutively to perform bilateral USG-guided ESPB at T9 level, using the out-of-plane technique. Blood samples were taken prior to ESPB and at 5th, 10th, 20th, 30th, 45th, 60th, 90th, 120th, 240th and 720th minutes after ESPB. Plasma bupivacaine concentration was measured using enzyme-linked immunosorbent assay (ELISA). Results 12 male and 5 female patients with mean age of 39.35±14.93 y were included. Peak mean plasma bupivacaine concentration was observed at 30m (0.022±0.010 μg/ml). The highest concentration was 0.041μg/ml at 60m, in one case. There was no difference in any of the measurements between men and women (p>0.05). Conclusions Twenty mL of 0.25% bupivacaine for ESPB at the lower thoracic level offers safe pharmacokinetics.
Background and Aims Propofol and dexmedetomidineare commonly used forsedation during regional anaesthesia. Although there are many studies comparing these two agents, none of the studies have compare the effect of these agents on diaphragmatic activity. Hence this trial was done after institutional ethics committee approval to evaluate whether dexmedetomidine sedation during regional anaesthesia preserves diaphragmatic thickness fraction compared to propofol sedation. Methods One hundred and twenty-six patients scheduled for elective surgery undergoing regional anesthesia were randomized into either dexmedetomidine (Group D) or propofol (Group P) sedation during surgery. For both the groups diaphragmatic ultrasound was done at baseline (T1), 20 minutes after the block (T2), after achieving a target bispectral index score (BIS) of 70–80 & Observer’s assessment of alertness/sedation (OAA/S) score of 3 (T3) & at the end of surgery after sedation has been stopped (T4). The primary objective was to compare diaphragmatic thickness fraction (DTF) at (T3) during surgery. The diaphragmatic excursion (DE) and velocity were compared as secondary outcomes. Results Significant difference was seen in percentage change in thickness fraction at T3 between group P and D (p value <.05). Mean of percentage increase in thickness fraction at T3 in group D was significantly higher as compared to group P. DE was also found to be significantly decreased in the Group P. Conclusions Dexmedetomidine sedation preserves the baseline diaphragmatic thickness in comparison to propofol.
Background and Aims Over the past years, tranexamic acid (TXA) has been used extensively to reduce blood loss during total joint arthroplasty (TJA).1 However, questions remain in respect to the risk of cardiac ischemic events, especially in those with coronary artery disease. We aimed to study if the use of TXA is associated with increased risk of myocardial infarction (MI) among 1) the overall population who underwent TJA, and 2) the population who had coronary artery disease before TJA. Methods This study is approved by Hospital for Special Surgery Institutional Review Board (IRB# 2016–436). We used Premier Healthcare database to identify patients undergoing TJA from 2006–2019, and their history of stent placement or coronary artery bypass graft (CABG) procedures. The primary exposure was intravenous TXA administration, and outcome is perioperative MI. Multilevel multivariable logistic regression models were performed to identify if TXA use was associated with perioperative MI. Results Out of all patients who underwent TJA, 44.7% received TXA. Upon adjusting for all covariates, patients who received TXA had a 30% lower odds of having MI compared to patients without TXA. After restricting the cohort to patients who received stent placements/CABG surgery before TJA, TXA administration was not significantly associated with perioperative MI. (Table 1) Conclusions In conclusion, we found that patients who received TXA were less likely to experience MI events in the TJA population. For patients who had coronary procedures before their joint arthroplasty, the use of TXA was not associated with an increase in the odds for MI.
This research analyzes the implications of the condition of “interinazgo” inthe relationship between the work experiences of an interim academic andadministrative population of the Faculty of Social Sciences and the Facultyof Philosophy and Letters of the National University (UNA), which allowsto know the sense of affiliation and belonging with the university, cooperation,and communication, among other aspects, of people who work in theinstitution. This article is a product of the advances of the research called“Implications of the condition of “interinazgo” in the subjectivity and relatedrelations of the working population of the National University”, whichis executed from the Political Threshold Program, of the Institute of SocialStudies in Population of the UNA. At the methodological level, eight semistructuredinterviews were conducted on the perceptions of each functionary;the analysis of the results is based on the theory of the Inverted Cone Schemeelaborated by Dr. Enrique Pichón Rivière, Social Psychologist. With the informationcollected, aspects related to the management of power, situationsof structural violence and institutional suffering that are experienced in theUNA are evidenced. Among the main findings obtained, it stands out that thecondition of “interinazgo” has implications in the daily life of the personsinterviewed reflected in each of the vectors of the inverted cone, such as thefeeling of belonging to the University, the commitment to their work and theover-demand in order to obtain the property (permanent hiring), among otheraspects of reality, faced by teachers and administrators called “non-owners”.
The 3GPP Turbo Encoder v5.0 offers the error correction and the high-speed data rate transmission for LTE at different high frequencies of operation. The execution of 3GPP Turbo Encoder v5.0 at a high frequency of operation increases the on-chip temperature of the encoder. The increase in on-chip temperature of 3GPP Turbo Encoder v5.0 at high frequencies may permanently damage the device and interrupt in data communication. Currently, different techniques have been reported but significant on-chip temperature consumption is not reduced for the on-chip temperature of 3GPP Turbo Encoder v5.0. In this paper, the thermal efficient design for 3GPP Turbo Encoder v5.0 is achieved using IO Standard technique. The 3GPP Turbo Encoder v5.0 is operated with and without IO Standards for different frequencies of operation (i.e. 10 MHz, 20 MHz, 30 MHz, 40 MHz, and 50 MHz) via Ultra Scale FPGA. More than 60% on-chip temperature reduction is achieved for the designed 3GPP Turbo Encoder v5.0 using HR IO standard. The designed 3GPP Turbo Encoder v5.0 using HR IO Standard offers low on-chip temperature consumption for error-free data transmission.
Healthcare and business solutions are transforming towards decentralized architectures. In this regard, many blockchain-based solutions have been proposed. Some are order-execute architecture while some are based on the execute-order architecture of blockchain. Execute-order architectures are famous for general purpose business applications. Hyperledger-composer is a smart-contract framework specically designed to model business apps comfortably. Hyperledger-composer supports role-based access control, however, it is new to adopt by Healthcare applications. The most important aspect of Healthcare applications is to provide access to sensitive documents. In this paper, we are formally dening constraint role-based access control (CRBAC) in Z formalization language to prove the properties of CRBAC in a Healthcare document sharing for blockchain, specically for Hyperledger-composer. The paper aims to take Health care document's access via constraint-based access control while the interface to the roles and documents are decentralized.
