Hodo Aideed Asowe,1,2 Samira Abdullahi Mo’alim,3 Mohamed Hussein Adam,2,4 Ahmed Mahad Sheikh Mohamed,2,4 Mohamed Adam Mahamud,2,3 Bashiru Garba,2,4 Jamal Hassan Mohamoud2,41Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, SIMAD University, Mogadishu, Banaadir, Somalia; 2SIMAD Institute for Global Health (SIGHt), SIMAD University, Mogadishu, Banaadir, Somalia; 3Department of Medical Laboratory, Faculty of Medicine and Health Sciences, SIMAD University, Mogadishu, Banaadir, Somalia; 4Department of Public Health, Faculty of Medicine and Health Sciences, SIMAD University, Mogadishu, Banaadir, SomaliaCorrespondence: Hodo Aideed Asowe, Email hodotani@simad.edu.soBackground: Safe anesthesia remains difficult to deliver in many resource-limited settings because of shortages of trained providers, monitoring equipment, oxygen, essential medicines, recovery facilities, and critical-care support. Spinal anesthesia is widely used for cesarean delivery and selected lower abdominal, urologic, perineal, and lower-limb procedures. Its contemporary use extends beyond the intrathecal injection to include patient selection, dose planning, hemodynamic management, multimodal analgesia, monitoring, postoperative observation, and rescue readiness.Objective: This narrative review examines the available evidence, implementation considerations, and minimum safety requirements for multimodal spinal anesthesia in Somalia and comparable resource-limited settings.Methods: A structured narrative literature search was conducted using PubMed/MEDLINE, Google Scholar, ScienceDirect, Cochrane-related sources, WHO and WFSA resources, and relevant global surgery literature. Sources addressing spinal or neuraxial anesthesia, obstetric anesthesia, multimodal analgesia, anesthesia safety, low-resource surgery, and Somalia’s anesthesia and critical-care context were considered. Evidence was synthesized thematically and categorized as published clinical evidence, international safety standards, contextual interpretation, or proposed implementation recommendations.Findings: Spinal anesthesia may reduce dependence on some components of general anesthesia infrastructure for appropriately selected patients, but it is not inherently safe. Minimum requirements include a trained provider, patient assessment, blood-pressure and oxygen-saturation monitoring, intravenous access, oxygen, vasopressors, airway rescue equipment, postoperative observation, and protocols for hypotension, failed block, high spinal block, and conversion to general anesthesia. Cesarean delivery represents an important area for standardization. Intrathecal adjuvants should be selected according to each facility’s monitoring and recovery capacity.Conclusion: Somalia-specific evidence on spinal anesthesia outcomes remains limited. The proposed framework should therefore be considered evidence-informed rather than locally validated. Prospective local audits are needed before claims regarding effectiveness, affordability, or improved outcomes can be made.Keywords: spinal anesthesia, neuraxial anesthesia, Somalia, low-resource settings, cesarean delivery, anesthesia safety, multimodal analgesia
Denis Buršík1–31Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic; 2Department of Anesthesiology, Resuscitation and Intensive Care Medicine, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic; 3Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech RepublicCorrespondence: Denis Buršík, Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic, Email denis.bursik@fno.cz
Yuan Xie,1 Yaxiong Gao21Department of Anesthesiology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, Gansu, 730000, People’s Republic of China; 2Department of Acupuncture and Tuina, Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, Gansu, 730000, People’s Republic of ChinaCorrespondence: Yaxiong Gao, Department of Acupuncture and Tuina, Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, Gansu, 730000, People’s Republic of China, Email Gao202508@foxmail.comAbstract: Postoperative sore throat (POST) is common after tracheal intubation, with pooled estimates of 32.4% at 1 hour and 16.4% at 24 hours in a recent systematic review. This narrative review examines how lidocaine delivery systems influence airway deposition, tolerability, duration of exposure, and safety. PubMed/MEDLINE and Crossref-indexed records were searched from inception through July 20, 2026, with backward citation tracking. Randomized trials, systematic reviews, pharmacology studies, and device or aerosol studies relevant to POST prevention or airway topicalization were prioritized. Direct spray is rapid, familiar, and inexpensive but produces operator-dependent deposition and may provoke coughing. Nebulization is gentler and useful for awake airway management, although delivered dose and anatomic coverage vary with the device and breathing pattern. Alkalinized intracuff lidocaine provides sustained exposure at the cuff–tracheal interface; in one 90-patient trial, POST occurred in 13% versus 67% of placebo recipients at 24 hours. Soft-mist delivery may reduce plume-related irritation, but its evidence base remains preliminary: a single-center 100-patient trial reported 24-hour POST in 4% versus 38% of controls, without comparison against optimized spray or nebulization. These estimates should not be compared as treatment rankings because populations and protocols differed. Lidocaine is best used selectively within a multimodal bundle that includes appropriate endotracheal-tube sizing, atraumatic intubation, cuff-pressure control, cumulative-dose accounting, and standardized outcome assessment. No delivery system has yet been shown to be definitively superior or most cost-effective.Keywords: postoperative sore throat, topical anesthesia, lidocaine, drug delivery, nebulization, endotracheal tube cuff, soft-mist device
Purpose:This study examined the effectiveness of the interscalene brachial plexus single-shot block (ISBSS) versus continuous block (ISBC) in managing acute and chronic postsurgical pain (PSP) in patients undergoing upper extremity surgery, and differences between the two groups in rehabilitation. Patients and Methods:Patients who underwent shoulder arthroscopy under locoregional anesthesia received either single-shot (ISBSS group) (n = 42) or continuous perineural catheter (ISBC group) anesthesia (n = 38). The primary outcome was the numeric rating scale (NRS) score related to PSP evaluation. Secondary outcomes included the American Shoulder and Elbow Surgeons Score (ASES), range of motion (ROM) in degrees, hospital length of stay, and opioid consumption, all measured postoperatively and during the rehabilitation evaluation. Results:ISBC group exhibited lower median [interquartile range, IQR] NRS score than ISBSS group at postoperative hour 20 (2 [2 to 3] vs 4 [2 to 5]), 24 (2 [2 to 2] vs 4 [1 to 5]), 48 (1 [1 to 2] vs 4 [4 to 5]), 72 (1.5 [1 to 2] vs 5 [4 to 5]) (P < 0.001, resp.); at postoperative day 7 (1 [1 to 2] vs 5 [5 to 6], P < 0.001) and postoperative month 1 (1 [1 to 1] vs 3 [3 to 3], P < 0.001). The ISBC group demonstrated lower opioid consumption, a better ASES score, and higher ROM grades at follow-up month 3 for flexion, abduction, and internal and external rotation (P < 0.001). Conclusion:Continuous interscalene brachial plexus catheter infusion may effectively control acute and chronic PSP, facilitating better rehabilitation and healing than single shot injection.
Wenjuan Qiao, Jie MengDepartment of Anesthesiology, The Second Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of ChinaCorrespondence: Jie Meng, Department of Anesthesiology, The Second Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China, Tel +86 17709871989, Email mandjie@163.com
Purpose:Thoracic epidural analgesia is widely considered the gold standard for postoperative pain management in abdominal surgery; however, it is associated with workflow limitations and potential hemodynamic instability. The modified thoracoabdominal nerve block through the perichondrial approach (m-TAPA) has emerged as an alternative technique for abdominal wall analgesia. This study aimed to compare the analgesic efficacy and perioperative impact of epidural analgesia and m-TAPA in patients undergoing robot-assisted colorectal surgery. Patients and methods:This retrospective, single-center, non-randomized cohort study included 45 adult patients who underwent robot-assisted laparoscopic colorectal resection between January and October 2024. Patients received either thoracic epidural analgesia (n = 23) or bilateral single-shot m-TAPA (n = 22), selected at the discretion of the attending anesthesiologist. The primary outcome was postoperative pain intensity assessed using the Numerical Rating Scale (NRS) at 4-hour intervals. Secondary outcomes included intraoperative and postoperative opioid consumption, time from operating room entry to surgical incision, vasopressor use, and analgesia-related complications. Results:Postoperative NRS scores were comparable between groups up to 16 hours after surgery. At 20 and 24 hours postoperatively, pain scores were significantly lower in the epidural group. Intraoperative and postoperative fentanyl consumption was significantly higher in the m-TAPA group (p < 0.01 for both comparisons). The time from operating room entry to surgical incision was significantly shorter in the m-TAPA group (p = 0.035). Postoperative bolus vasopressor therapy was more frequently required in the epidural group (p = 0.0045). The incidence of postoperative nausea and vomiting, atelectasis, neurological complications, urinary retention, and intensive care unit length of stay did not differ significantly between groups. Conclusion:In this small retrospective cohort, m-TAPA provided comparable early postoperative analgesia but was associated with higher opioid consumption compared with epidural analgesia. Given the non-randomized design, small sample size, and differences in analgesic duration between techniques, these findings should be interpreted with caution. m-TAPA may represent a practical alternative in selected patients; however, further prospective studies are required to confirm these findings.
Background:Laparoscopic cholecystectomy (LC) is the gold standard of treatment for symptomatic cholelithiasis. Despite its minimally invasive nature, LC is still associated with moderate postoperative pain that may delay early mobilization, oral intake, and discharge while increasing the need for opioids. Within ERAS protocols, multimodal analgesia using regional techniques has become increasingly important. The rectus sheath block (RSB) is considered a useful option for controlling the somatic pain component related to the periumbilical port site. Materials and Methods:A narrative literature review was conducted using PubMed, Scopus, and Google Scholar to identify studies published up to 2026. The analyses included prospective randomized and non-randomized studies, retrospective case series, anatomical investigations, and expert recommendations. In addition to the classical RSB, the deep rectus sheath block (DRSB) was evaluated as a potentially relevant technique for addressing not only somatic but also peritoneum-related pain. Results:Classical RSB, performed by injecting local anesthetic between the rectus abdominis muscle and the posterior rectus sheath, provides effective analgesia in the periumbilical port area, reduces postoperative pain intensity, and decreases opioid consumption during the first 24 h after LC compared with wound infiltration or systemic analgesia alone. DRSB, which targets the preperitoneal plane between the posterior rectus sheath and parietal peritoneum, has shown promising analgesic effects in isolated clinical reports after LC and epigastric hernia repair, with possible benefits for peritoneum-related pain. However, the current evidence for DRSB remains limited to case reports and small case series, and its exact mechanism of action is still debated. Conclusion:RSB is a valuable component of multimodal analgesia for LC, with a demonstrated opioid-sparing effect and favorable safety profile under ultrasound guidance. DRSB appears promising, but remains experimental. Further well-designed randomized trials are needed to define its indications, optimal technique, and role in standardized analgesic protocols for LC.
Background:Postoperative delirium (POD) is a common complication in elderly patients with hip fracture. This study aimed to investigate the occurrence of POD in patients receiving continuous fascia iliaca compartment block (CFICB) with an opioid-containing solution, and review current evidence. Case Presentation:We retrospectively analyzed four elderly patients (aged 73-90 years) who developed delirium after receiving opioid-containing CFICB for hip fracture surgery. All received ultrasound-guided CFICB with ropivacaine 0.25% (loading dose 40mL) followed by continuous infusion (sufentanil 50μg + ropivacaine 100mg in 240mL saline at 3mL/h). The Montreal Cognitive Assessment (MoCA) was administered on admission. Patient characteristics were: Case 1 (73-year-old female, delirium onset postoperative day 4, MoCA = 26); Case 2 (90-year-old male, delirium onset postoperative day 2, MoCA = 18, surgery delayed 6 days); Case 3 (75-year-old male, delirium onset within 24 hours of surgery, MoCA = 28); Case 4 (87-year-old female, delirium occurred on the day of the block placement, MoCA = 15). Despite excellent post-CFICB pain control Visual Analog Scale (resting VAS ≤ 3) in all patients, delirium occurred, with durations ranging from 36 hours to 120 hours. Conclusion:This small case series (n = 4) suggests that opioid-containing CFICB provides effective perioperative analgesia for elderly hip fracture patients but does not completely prevent postoperative delirium, particularly in patients with advanced age, baseline cognitive dysfunction, or delayed surgery. Given the retrospective design and small sample size, these findings are exploratory only. Larger prospective studies are needed.
Background:The influence of obstetric anesthesia on neonates is still under investigation. We aimed to investigate the influence of type of anesthesia; either general anesthesia (GA) or spinal anesthesia (SA); during elective or emergency cesarean section (CS) on neonatal outcomes. Methods:A retrospective cohort study was conducted and all neonatal admissions to the neonatal intensive care unit for mothers who underwent elective or emergency CS as the mode of delivery during the period from 2017 to 2021 were enrolled in the study. The primary outcome of the study was to investigate the difference between SA and GA. The enrolled cohort was divided into two groups: GA and SA groups. Results:A total of 997 patients were included in the study cohort. Among these, 628 patients underwent CS under SA. On univariate analysis, it was revealed that SA was associated with better Apgar score (8.56 ± 0.04 vs 8.16 ± 0.05, P =0.0001), less incidence of respiratory distress syndrome (RDS) (35.5% vs 42.3%, P =0.02), intraventricular hemorrhage (IVH) (0.8% vs 13.6%, P =0.0001), and neonatal thrombocytopenia (12.4% vs 17.3%, P =0.021). Moreover, GA was linked to higher mortality rates (10.8% vs 4%, P =0.0001) and more birth depression (10.6% vs 4.3%, P =0.0001). On the other hand, GA was related to less incidence of transient tachypnea of the newborn (TTN) (6.2% vs 12.6%, P =0.001). On multivariate logistic regression analysis, mode of anesthesia was related to RDS, TTN, IVH, birth depression and neonatal death. Conclusion:GA use may be related to more adverse and worse neonatal outcomes. This is related to the utilization of GA more frequently in higher-grade emergencies and is associated with more adverse baseline predictors including lower gestational age, lower birth weight, and greater obstetric complications. SA could offer a localized effect for the anesthetic drugs. Further prospective trials are needed to justify the risk of both types of anesthesia.
Background:Hip fractures (HF) are a serious and increasingly common condition in the geriatric population. Favorable clinical outcomes require early postoperative rehabilitation, which relies on effective pain management. Intrathecal morphine (ITM) is a well-established method of perioperative analgesia, but concerns have been raised about potential adverse effects in the elderly population. This superiority trial was designed to compare the efficacy and safety of low-dose intrathecal morphine, with adverse effect prevention, versus a standard multimodal analgesic regimen in elderly patients undergoing surgery for hip fracture repair. Methods:Patients aged 60-90 years scheduled for HF surgery under single spinal anesthesia were randomized into two groups: bupivacaine/levobupivacaine with 100 µg ITM, and bupivacaine/levobupivacaine alone. The primary outcome was pain intensity (11-point numeric rating scale; NRS) during the first 24 hours after surgery. Secondary outcomes included postoperative analgesic consumption, time to first analgesic, and incidence and severity of adverse effects. Results:This study enrolled 82 patients; 47 (57.3%) were allocated to the intervention group, 34 (41.5%) to the control group. The median 24-hour postoperative NRS score was 0.39 (IQR 0.00-0.90) in the intervention group, and 1.70 (IQR 1.23-1.91) in the control group (p < 0.001). Time to first analgesic was 16.5 hours (IQR 8.75-24.00) in the intervention group, and 7 hours (IQR 4.62-9.88) in the control group (p < 0.001). No postoperative analgesics were required for 29.8% of patients in the intervention group, and 2.9% of patients in the control group (p = 0.001). The incidence and severity of adverse effects did not significantly differ between the groups. Conclusion:Compared to standard multimodal analgesia, low-dose ITM significantly reduced postoperative pain and analgesic consumption, and prolonged the time to first analgesic administration, without an increased incidence or severity of adverse effects in elderly patients with HF.
Purpose:To evaluate whether continuous peripheral nerve blocks (PNBs) are independently associated with reduced early opioid consumption and improved pain outcomes in older adults with hip fractures. Methods:Patients aged ≥65 years admitted with hip fractures were included in this retrospective cohort study and categorized into a PNB group (continuous fascia iliaca compartment block or continuous femoral nerve block) and a control group without peripheral nerve block. The primary outcome was cumulative fentanyl-equivalent opioid consumption within 24 hours after admission. Secondary outcomes included pain intensity (Numeric Rating Scale [NRS]), postoperative opioid consumption within 24 hours after surgery, delirium, length of hospital stay, and catheter-related complications. Multivariable linear regression adjusted for age, sex, ASA physical status, fracture type, and time to surgery. Results:In total, 203 patients were analyzed (PNB, n = 147; control, n = 56); 36.0% underwent surgery within 48 hours of admission. Opioid consumption within 24 hours after admission was lower in the PNB group (median [IQR]: 50 [0-90] µg vs 100 [60-150] µg; p < 0.001). After adjustment, continuous PNB remained independently associated with reduced opioid consumption within 24 hours after admission (adjusted β -43.8 µg; 95% CI -59.3 to -28.3; p < 0.001) and within 24 hours postoperatively (adjusted β -63.2 µg; 95% CI -79.7 to -46.7; p < 0.001). Pain scores improved after block placement and remained lower at 24 hours after admission and postoperatively. Longer time to surgery was independently associated with increased opioid consumption. Delirium, length of stay, and catheter-related complications did not differ significantly between groups. Conclusion:In older adults with hip fractures, continuous peripheral nerve block was independently associated with reduced opioid consumption and improved perioperative pain control, and may support perioperative analgesia in healthcare settings where surgical delay is common.
Craniofacial complex regional pain syndrome (CRPS) is a rare, diagnostically challenging condition characterized by sympathetically maintained pain, allodynia, and autonomic features in the craniofacial region. Its overlap with trigeminal autonomic cephalalgias (TACs) creates significant diagnostic complexity. We report the case of a 41-year-old male with a 12-year history of severe right-sided hemicranial and facial pain with prominent autonomic features (facial edema, ptosis, lacrimation, allodynia) following plastic surgery in occipital area, in a patient with a prior history of CRPS. After failing extensive pharmacological management (including indomethacin, verapamil, topiramate, pregabalin, carbamazepine, lamotrigine, lithium and lidocaine infusions) and numerous interventional procedures (peripheral nerve blocks, Sphenopalatine ganglion (SPG) blocks, pulsed radiofrequency of SPG and Gasserian ganglion), the patient underwent sequential neuromodulation: occipital nerve stimulation (ONS) followed by sphenopalatine ganglion (SPG) stimulation seven years later. This combined approach resulted in sustained pain reduction from NRS 9-10/10 to 1-2/10, attack frequency reduction from 1-2 daily to rare exacerbations, and complete discontinuation of all analgesic medications over a 12-year follow-up. This case demonstrates that combined ONS and SPG stimulation may provide effective longterm pain relief in refractory craniofacial pain irrespective of whether the underlying diagnosis is craniofacial CRPS or secondary TAC, and highlights the value of sequential neuromodulation when single-modality approaches are insufficient.
Introduction:The primary aim of this study was to compare the continuous suprainguinal fascia iliaca block (CSFI) and continuous epidural analgesia (CEA) for procedures of the proximal femur and acetabulum in children. We hypothesized that CSFI would provide equivalent opioid requirements while both blocks were in place, reduced opioid requirements after epidural removal, earlier mobilization, and decreased length of stay compared to CEA. Materials and Methods:We retrospectively examined all pediatric patients who underwent a procedure of the proximal femur or acetabulum between January 1, 2013, and December 31, 2023. Outcome measures included opioid usage, verbal pain scores (0-10), sedation scores, time to ambulation and length of hospital stay. The primary endpoint was daily opioid requirements. Results:There were 82 patients in the cohort, 35 patients in the CEA group and 47 patients in the CSFI group. We found no evidence for differences in daily mean opioid requirements (parenteral and oral) for the two groups on the day of surgery (DOS) and POD 1 when both blocks were in place. CSFI was strongly associated with lower mean opioid requirements on POD 2 and POD 3 following removal of the epidural catheter, earlier time to ambulation, shorter length of stay and less sedation on the DOS, POD 1, and 2. Four patients reported persistent anterior thigh numbness 6 weeks after the procedure, all in the CSFI group. (8.5%). Conclusion:CSFI was associated with similar parenteral and oral opioid requirements compared to CEA while both blocks were in place, earlier mobilization, reduced length of stay, less sedation and reduced opioid usage after epidural removal. CSFI appears to offer significant advantages over CEA for procedures of the proximal femur and acetabulum in pediatric patients, but persistent thigh numbness in the CSFI group warrants further investigation.
Background and Aim:Neuraxial anesthesia is commonly used for intertrochanteric fracture surgery but may be contraindicated in frail elderly patients, particularly in the presence of anticoagulation or urgent surgical settings. The Lumbar Erector Spinae Plane Block (L-ESPB) has been proposed as a para-neuraxial technique potentially suitable as a main anesthetic strategy. This study aimed to evaluate whether L-ESPB could represent a viable alternative to Spinal Anesthesia (SA) combined with a Pericapsular Nerve Group (PENG) block in patients undergoing urgent intramedullary nailing for intertrochanteric fractures. Methods:This multicenter comparative pilot study included ≥65 years undergoing surgery within 48 hours of hospital admission, between May and November 2025. Fifty patients were analyzed: 24 received L-ESPB as the sole anesthetic technique, and 26 received SA combined with a PENG block. The comparison focused on anesthesiologic plane adequacy, intraoperative hemodynamic stability, and postoperative recovery outcomes. Results:An adequate anesthesiologic plane was achieved in all patients. Sensory and motor block onset was faster and more intense in the PENG + SA group. Intraoperatively, hemodynamic stability was more frequently preserved in the L-ESPB group (58.3% vs 19.2%, p = 0.02), despite similar surgical duration. Intraoperative ketamine rescue was required in a small proportion of patients in the L-ESPB group. Postoperatively, time to mobilization was shorter in the PENG + SA group, whereas pain scores remained low in both groups, with minimal need for rescue analgesia and no relevant anesthesia-related adverse events. Conclusion:L-ESPB provided effective surgical anesthesia and was associated with greater intraoperative hemodynamic stability compared with SA combined with PENG block. These preliminary findings suggest that L-ESPB may represent a feasible alternative in elderly patients with contraindications to neuraxial anesthesia, warranting confirmation in larger prospective studies.
Effective perioperative pain control is essential in Total Knee Arthroplasty (TKA) to support early mobilization and enhance recovery, particularly within Enhanced Recovery After Surgery (ERAS) protocols. The use of a thigh tourniquet, although common, is increasingly questioned due to its association with postoperative pain and thromboembolic risk, especially in patients with a history of Deep Vein Thrombosis (DVT). Periarticular Vasoconstrictor Infiltration (PVI) is a recently described technique aimed at achieving localized hemostasis through epinephrine-based infiltration. This case report illustrates the clinical utility of ultrasound-guided PVI as part of a multimodal, tourniquet-free strategy in high-risk patient. A 66-year-old female with severe right knee osteoarthritis and a history of right lower limb DVT underwent primary TKA under spinal anesthesia. Due to the patient's elevated thrombotic risk-defined by a high Caprini score-a tailored regional anesthesia protocol was adopted, combining multi-target PVI with a proximal adductor canal block and spinal anesthesia. The PVI solution included ropivacaine, dexmedetomidine, and epinephrine. No tourniquet was inflated during the procedure. The surgical field remained bloodless throughout the 72-minute procedure. Intraoperative blood loss was less than 200 mL, and no transfusion was required. Postoperative analgesia was effective, opioid use was minimized, and the patient mobilized the same evening without complications. No clinical or ultrasound signs of early postoperative thrombotic events were observed. This case demonstrates the feasibility and clinical benefit of integrating ultrasound-guided PVI into a multimodal, tourniquet-free anesthetic strategy for TKA in high-thrombotic-risk patients. The approach provided effective analgesia and hemostasis, aligned with ERAS principles, and may represent a valuable alternative for personalized perioperative care in orthopedic surgery.
Purpose:Caudal block remains a standard regional anesthesia technique for pediatric lower abdominal and lower limb surgeries. The conventional weight-based Armitage formula does not consider patient body habitus, which can lead to under- or over-dosing-especially in lean or obese children. Ultrasound guidance permits visualization of epidural spread and may facilitate individualized dosing. Patients and Methods:In this retrospective single-center study, anesthetic records of 25 pediatric patients (age 10-106 months) undergoing ultrasound-guided caudal blocks for lower abdominal or lower extremity surgery were analyzed. Volumes of 0.25% levobupivacaine required to achieve cranial spread to vertebral levels S1, L2 and L1 were recorded. Univariate and multivariate linear regression models, incorporating weight, height, age, and BMI, were compared using adjusted R2, mean squared error (MSE), Akaike information criterion (AIC), and Bayesian information criterion (BIC) to determine the most predictive dosing formulae. Results:Univariate regression revealed injected volume correlated strongest with weight: for S1 spread, volume = 0.1458 × weight (kg) (p = 0.006); for L2 spread, volume = 0.4898 × weight (kg) (p = 0.0079). The optimal multivariate model for S1-level spread combined weight and height: Volume (mL) = 0.1741 × weight (kg) - 0.0234 × height (cm) (adjusted R2 = 0.1369; lowest AIC/BIC). For L2-level spread, a weight-only model (volume = 0.5339 × weight [kg]) provided the best fit (adjusted R2 = 0.2112). Both models predicted lower volumes than the traditional Armitage guideline, reducing the likelihood of excessive cephalad spread. Conclusion:In pediatric caudal anesthesia, a dosing formula that uses both weight and height improves prediction of the volume required for S1-level blocks, whereas a weight-based formula is adequate for L2-level spread. Real-time ultrasound guidance enhances procedural accuracy and safety by confirming epidural spread and detecting anatomical variation. These data support development of an individualized dosing nomogram for pediatric caudal anesthesia.
Objective:To evaluate the efficacy of modified cocktail analgesia in relieving pain after minimally invasive chevron osteotomy for hallux valgus. Methods:A retrospective cohort study was conducted to analyze the clinical data of 90 patients with moderate to severe hallux valgus admitted to our hospital from January 2020 to December 2023. Based on the treatment method and the number of affected limbs, the patients were divided into three groups: the modified group (Imp) treated with minimally invasive chevron and Akin (MICA) osteotomy combined with modified cocktail therapy, the traditional group (Tro) treated with MICA osteotomy combined with conventional cocktail therapy, and the control group (NC) treated with MICA osteotomy alone without cocktail therapy. The visual analog scale (VAS) scores for ankle-foot pain from 6 hours preoperatively to 14 days postoperatively, the need for postoperative rescue analgesia, adverse reactions, and complications were observed and compared among the three groups. Results:There were no significant differences in basic conditions such as age and BMI among the three groups. It is in line with the epidemiological statistics of hallux valgus in terms of gender. The VAS scores at 6 hours and 1 day postoperatively were significantly lower in the modified group [(0.67±0.60), (0.68±0.59) respectively] compared to the traditional group [(0.82±0.50), (0.78±0.90) respectively] (P < 0.05). There were no statistically significant differences in VAS scores between groups at 6 hours preoperatively and 7 days and 14 days postoperatively (P > 0.05). Five patients (5.56%) in the modified group required postoperative rescue analgesia, which was significantly fewer than the 12 patients (13.33%) in the traditional group (P < 0.05). Conclusion:Based on the comprehensive statistical results and clinical significance, the modified cocktail therapy has certain clinical reference value in the short-term analgesia management after MICA. It is beneficial for the early postoperative rehabilitation functional exercise of patients and has a good safety effect. It can be used as an optional option for early postoperative pain control. However, it is necessary to objectively recognize the timeliness of its therapeutic advantages. Its long-term analgesic effect shows no significant clinical difference from the traditional cocktail therapy and the simple MICA procedure.
Purpose:Peripheral nerve block safety and pharmacology for patients with inherited antithrombin III (ATIII) deficiency remains unclear because of the rarity of the disease. Here, we report a case of unexpectedly prolonged motor and sensory inhibition following single-shot femoral and sciatic nerve blocks in a patient with inherited ATIII deficiency. We hypothesized that venous stasis, microcirculatory impairment, elevated peripheral venous pressure, and increased local tissue pressure might have contributed to prolonged nerve dysfunction and peripheral nerve injury. Case Report:The patient was a 58-year-old man (170 cm, 69 kg) with inherited ATIII deficiency. He was scheduled for 1-hour surgical debridement of recurrent venous stasis ulcers with microcirculatory impairment on his lower left leg. Nerve blocks resulted in motor and sensory deficits in the lower leg that lasted 2 and 8 days, respectively. The prolonged duration of this nerve block might have been related to his inherited ATIII deficiency. This condition can contribute to thrombosis of vessels such as the inferior vena cava, potentially leading to venous microcirculatory impairment in the lower limbs and complex coagulopathy. Conclusion:While peripheral nerve blocks are widely used for their efficacy and safety, the risk-benefit profile of regional anesthesia may be atypical in patients with coagulation disorders. This case highlights the need for cautious nerve block administration in patients with inherited ATIII deficiency.
Background:Despite its association with severe postoperative pain, the use of regional anesthesia techniques for penile-inversion vaginoplasty surgery is understudied. This retrospective study aimed to assess the analgesic effects of a saddle block (ultra-low dose hyperbaric spinal anesthesia) with intrathecal (IT) morphine in transgender females undergoing penile inversion vaginoplasty. Methods:We performed a single-centre, retrospective chart review of 72 patients who underwent penile-inversion vaginoplasty with or without saddle block with IT morphine at our institution over a 26-months period. All patients received standard multimodal intravenous analgesia, and the surgeon administered both a pudendal nerve block and a spermatic cord block as part of routine care. Our primary outcome was cumulative opioid consumption (oral morphine equivalent) at 24h postoperatively. Secondary outcomes included postoperative pain severity, duration of stay in the postoperative care unit and in-hospital, time to first opioid request and incidence of opioid- and block-related side effects. Results:30 patients received a saddle block with IT morphine and 42 patients received standard analgesia. We found no statistical difference in cumulative opioid consumption at 24h postoperatively (control group: 17.7 mg [5.6, 30.8] vs intervention group 12.5 mg [7.5, 22.5] P: 0.249). The addition of a saddle block was associated with clinically and statistically significant improvements in short-term postoperative pain-related outcomes in the recovery room, including mean and maximum pain severity scores, time to first analgesic request, and duration of stay. While no difference in pain scores was detected at the 24-hour time point, mixed-effects modelling demonstrated lower pain trajectories over time among patients in the intervention group, suggesting a time-dependent benefit. However, the significant time-by-group interaction (p = 0.024) indicates that the difference in pain scores between groups decreased over time. We found no differences in the rates of nausea and vomiting between groups. No saddle block procedure-related complications were reported. Conclusion:This retrospective study suggests that despite no statistically significant difference in 24-hour opioid consumption, the addition of a saddle block with 100 mcg of IT morphine is associated with improved PACU pain scores, a longer time to first analgesic request, and a shorter PACU stay. These findings are hypothesis-generating and merit further investigation in a prospective double-blind randomized controlled trial.
Purpose:External oblique intercostal (EOI) block has recently emerged as a promising analgesic method for the upper abdominal surgery. This study aimed to assess the effect of EOI block on postoperative analgesia and early recovery following open liver resection (OLR). Patients and Methods:In this prospective, randomized, controlled trial, 64 patients scheduled for OLR were randomly allocated into EOI group and control group. EOI group received 30 mL of 0.25% ropivacaine bilaterally 30 min before induction of general anesthesia, whereas control group did not receive any block. The primary outcomes were sufentanil consumption 24 h after surgery. The secondary outcomes mainly included: the visual analogue scale (VAS) pain scores at rest and on coughing at 2, 12, 24, 48 h postoperatively; number of analgesia pump compression 24 h postoperatively; quality of recovery-15 (QoR-15) scale score 48 h after surgery; Pittsburgh sleep quality index (PSQI) score the first night postoperatively; and plasma levels of norepinephrine (NE), cortisol (Cor), high mobility group box protein 1 (HMGB1), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) 1h before surgery and 6 h postoperatively. Results:A total of 60 patients had completed the study (n = 30 per group). Sufentanil consumption 24 h postoperatively in EOI group was less than that in control group (mean difference: 4.45 μg, 95% CI, 1.6-7.2, P=0.003). The VAS scores at 2, 12, 24 h postoperatively; number of analgesia pump compression; and PSQI scores were significantly lower in EOI group than in control group. QoR-15 scale scores were higher in EOI group. The plasma levels of NE, Cor, HMGB1, TNF-α and IL-6 at 6 h postoperatively in EOI group were significantly lower than in control group. Conclusion:EOI block given to patients undergoing OLR could provide effective postoperative analgesia, enhance the quality of postoperative recovery, and attenuate postoperative stress and inflammation.
