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Vol 18, No 1 (2024)

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Reviews

Current methods of perioperative analgesia for arthroscopic anterior cruciate ligament reconstruction: a literature review

Gorelov D.V., Babayants A.V., Ovechkin A.M.

Abstract

Arthroscopic knee joint surgery is becoming routine in modern orthopedics. Its advantages include minimal invasiveness, lower infection risk, and early rehabilitation. Despite the minimized surgical trauma, the postoperative period after some arthroscopic operations involving cruciate ligament surgery occurs with relatively severe pain syndrome. This warrants the search for novel pain relief methods for patients that meet all modern trends. This review presents data from randomized clinical studies and meta-analyses on the use of various anesthesias in arthroscopic cruciate ligament repair and discusses methods of prolonged postoperative analgesia. The limited number of studies on this issue and lack of systematic recommendations require prospective studies.

Regional Anesthesia and Acute Pain Management. 2024;18(1):5-16
pages 5-16 views

Modern methods of regional and postoperative anesthesia during cesarean section: a literature review

Korobka M.N., Pichugina V.M., Khazieva A.R., Borisov A.V., Stepanova A.V., Safina D.A., Strelnikova P.A., Udagova A.A., Tarasenko E.A., Grezin A.G., Mukhamadiyarova K.R., Filippov A.A., Krestyaninova V.V.

Abstract

The number of cesarean section (CS) deliveries increases annually in Russia. General anesthesia involves certain risks, including difficult or unsuccessful intubation, aspiration, and infectious and thromboembolic complications. Therefore, regional anesthesia is the method of choice for CS. To date, choosing the most effective method of regional anesthesia remains challenging, including in the postoperative period. Thus, this review aimed to compare the effectiveness of regional anesthesia methods used in CS and identify the most preferred ones for use in clinical practice. The authors conducted a literature search in the electronic databases PubMed (MEDLINE), eLibrary, and Google Scholar using the following keywords and their combinations in English and in Russian: «cesarean section», «neural morphine», «regional analgesia», «epidural analgesia», «peripheral nerve block», nerve block», «paravertebral block», «cesarean section», neuroaxial use of opioids», «regional analgesia», «epidural analgesia», «peripheral nerve blockade», «blockade», and «paravertebral blockade». The search results revealed 3 558 in the PubMed database, 94 in eLibrary, and 2 662 in Google Scholar. The results show that the neuroaxial administration of opioids remains the gold standard of pain relief after CS; however, information on the analgesic effectiveness of new blockades, such as anterior block of the quadratic lumbar muscle and block of the muscle straightening the spine, continues to accumulate.

Regional Anesthesia and Acute Pain Management. 2024;18(1):17-32
pages 17-32 views

History and prospects for the use of morphine in clinical practice: literature review

Raspopin Y.S., Shifman E.M., Feoktistova D.A.

Abstract

The authors analyzed various studies on acute and chronic pain syndrome treatment. This review provides brief historical data on the discovery and use of morphine from ancient times to present. Morphine remains one of the most common painkillers worldwide and has a rich history dating back more than 200 years. Its basic properties, pharmacokinetics, pharmacodynamics, and principles of use are discussed. No drug has had such an impact on society as morphine because of its medical use as a pain reliever and its illicit use as a drug of addiction and abuse. This review includes the main modern recommendations for the treatment of acute and chronic pain, particularly from the World Health Organization for the treatment of chronic pain and the Procedure-Specific Postoperative Pain Management (PROSPECT) group for the treatment of postoperative pain in various surgical interventions. The types of opioids and their clinical use are described, and the authors’ opinion on the current use of morphine for treating acute and chronic pain syndrome is presented.

Regional Anesthesia and Acute Pain Management. 2024;18(1):33-40
pages 33-40 views

Original study articles

Predicting severe pain after cesarean section: prospective cohort study

Shindyapina N.V., Marshalov D.V., Shifman E.M., Kuligin A.V.

Abstract

BACKGROUND: Severe and unbearable pain after abdominal delivery is recorded in 20% of cases, indicating the limitations of the applied methods of postoperative pain relief and the need for a personalized approach. Tests assessing preoperative pain threshold and anxiety have the greatest sensitivity and specificity as predictors of intense postoperative pain. The informative value of these tests in the Russian obstetric population has not been assessed.

OBJECTIVE: This study aimed to determine the optimal method for predicting severe pain after cesarean section (CS).

MATERIALS AND METHODS: This prospective cohort study included 212 women who underwent elective CS under spinal anesthesia. The Hospital Anxiety and Depression Scale (HADS) anxiety rating scale, pressure algometry, and cutaneous infiltration anesthesia pain intensity assessment were used as predictors of high-intensity pain. Postoperative pain intensity was assessed using a 10-point Numeric Rating Scale (NRS). The maximum level of pain according to the central pain level at rest (NRSr) and during movement (NRSa) was recorded 24 hour postoperatively. The number of requests for “rescue analgesia” was recorded. The predictive value of the studied methods was determined based on ROC curve analysis.

RESULTS: Median (interquartile range) NRSa was 5 [4–5]. Severe pain was recorded in 14% of the patients. The area under the ROC-curve (AUC), reflecting the relationship between severe postoperative pain and pressure-pain threshold, was 0.91±0.03 with 95% confidence interval (CI) of 0.84–0.97 (p <0.001). The relationship between pain intensity during infiltration anesthesia and postoperative pain severity had AUC=0.88 ± 0.04 with 95% CI of 0.81–0.96 (p <0.001). The HADS anxiety score demonstrated the lowest predictive ability (AUC=0.69±0.06; 95% CI, 0.81–0.96; p <0.001). When all three techniques were used together, the AUC was 0.924±0.024 with 95% CI 0.88–0.97 (p=0.001).

CONCLUSION: Preoperative pressure-pain threshold and pain severity during infiltration anesthesia are reliable predictors of severe pain after CS. Assessment of preoperative anxiety using HADS has low sensitivity and specificity. However, its use in conjunction with methods for assessing the pain threshold increases the predictive value of the combined model compared with the results of using the methods separately.

Regional Anesthesia and Acute Pain Management. 2024;18(1):41-52
pages 41-52 views

Comparative evaluation of two methods of prolonged femoral nerve block using an elastomeric pump after knee arthroplasty: a prospective randomized controlled study

Krylov S.V., Pasechnik I.N.

Abstract

BACKGROUND: The number of knee arthroplasty (KA) surgeries is increasing annually. These surgeries are associated with severe pain. The optimal method of choice in perioperative analgesia in these patients remains controversial. The use of regional analgesia, including prolonged analgesia, allows for high pain relief and increased patient satisfaction. Modern elastomeric pumps (EP) provide prolonged conduction analgesia, which significantly expands the possibilities of perioperative pain relief.

OBJECTIVE: To evaluate the effectiveness of prolonged femoral nerve block using EP with and without bolus after KA.

MATERIALS AND METHODS: This prospective randomized study included 75 patients who were divided into two clinical groups: group 1 (n=36), patients who received prolonged regional analgesia using EP with controlled injection without bolus, and group 2 (n=39), patients who received prolonged regional analgesia using EP with bolus. In the postoperative period, the level of pain at rest and during movement was assessed after 6, 12, 24, and 48 hours as well as the need for opioid analgesics, consumption of local anesthetic for various options of continued regional analgesia, quadriceps femoris muscle function, and distance traveled by patients after surgery in the first 2 days.

RESULTS: No significant differences were noted in pain level at rest and during movement in the observation period between the groups (p=0.213). No additional prescription of opioid analgesics was required. Local anesthetic consumption was lower in group 2 (group 1.384±33.4 ml; group 2.237±25.1 ml; p=0.031). Patients in group 2 had greater activity in knee extension and, thus, greater distance traveled after surgery.

CONCLUSION: The use of EP with a bolus has been demonstrated to provide adequate levels of analgesia and better functional recovery in patients with bolus after KA than in patients without bolus. This technique is recommended as a component of enhanced recovery program after surgery.

Regional Anesthesia and Acute Pain Management. 2024;18(1):53-62
pages 53-62 views

Use of concomitant anesthesia (endotracheal anesthesia and femoral nerve block) in cardiac surgery: a prospective, cross-sectional study

Klepcha T.I., Dudko V.A., Lipnitskiy A.L., Marochkov A.V.

Abstract

BACKGROUND: Regional anesthesia reduces pain impulse transmission, which reduces hormonal and metabolic responses to operational stress. No studies have reported on the use of combined anesthesia, such as endotracheal anesthesia and femoral nerve block, in cardiac surgery.

OBJECTIVE: To determine the efficacy of combined anesthesia by analyzing the cortisol, glucose, and lactate levels in cardiac surgery.

MATERIALS AND METODS: Prospective cross-sectional study was conducted. The study included 60 cardiac surgery patients. The patients were divided into two groups: group 1, with endotracheal anesthesia and femoral nerve blockade, and group 2, with endotracheal anesthesia (control group). All patients underwent aortocoronary bypass grafting under artificial circulation conditions. Cortisol, glucose, and lactate levels at the five stages of the perioperative period were investigated.

RESULTS: Data analysis showed that the cortisol level of patients with combined anesthesia was significantly 1.2 times lower (p=0.042) than that in the control group in step 2. Glucose levels were significantly lower in the combined anesthesia group by 1.28 times (p=0.0017) than in the control group in step 4 and significantly lower by 1.2 times (p=0.0016) in step 5. Additionally, lactate level was significantly lower in the combined anesthesia group than in the control group in step 4 by a factor of 1.3 (p=0.03) and in step 5 by a factor of 1.35 times (p=0.005).

CONCLUSION: The determination of cortisol, glucose, and lactate levels can be used as a component of endocrine-metabolic anesthesiological monitoring when performing cardiac surgery under artificial circulation conditions. Stable parameters of endocrine-metabolic monitoring were established using both anesthesia methods. The use of femoral nerve block in combined anesthesia reduces stress response to surgery.

Regional Anesthesia and Acute Pain Management. 2024;18(1):63-71
pages 63-71 views

Erector spinae plane block as a component of intensive care for acute pancreatitis: a prospective randomized pilot study

Shapkin M.A., Sholin I.Y., Cherpakov R.A., Suryakhin V.S., Koriachkin V.A., Safin R.R.

Abstract

BACKGROUND: Analgesia is crucial in the treatment of patients with acute pancreatitis, which includes the increased use of regional analgesia. In recent years, less-invasive and safer methods of pain relief, particularly erector spinae plane block (ESP-block), has drawn attention from the anesthesiological community. However, studies on its use in acute pancreatitis are rare.

OBJECTIVE: Our aim was to make a clinical evaluation of bilateral erector spinae plane block in patients with acute pancreatitis.

MATERIALS AND METHODS: A pilot prospective randomized study was conducted. The patients were divided into two groups: group 1 (n=7), ESP blockade was used, and group 2 (n=12), epidural analgesia (EA) was used. The primary points were considered to be an assessment of pain syndrome intensity and the need for analgesics. Additional results were liver and kidney function, acid-base condition, inflammatory response level, and the time of onset of peristalsis.

RESULTS: The decrease in pain intensity in both groups was unidirectional: after 8 h, it was 3.57±1.98 points to the NRS in group 1 and 2.91±1.97 points to the NRS in group 2, and after 24 h, it was 1.42±1.27 and 1.75±2.3 points to the NRS, respectively. No significant difference was found in pain intensity between the groups (р >0,05). The average consumption of ketorolac was 78.2±16.3 mg in group 2 — 63.28±17.23 mg for 1 patient. The average need for narcotic analgesics, that is, morphine, per patient was 22±8 mg in group 1 and 36.3±17.2 mg in group 2 (р <0,05). During the therapy, blood α-amylase, diuresis rate, creatinine level, and glomerular filtration rate did not have a significant difference between the groups, as well as pH, BE, and blood lactate levels (р >0,05). Peristalsis was noted after 12.49±19.73 h in the ESP-block group and after 16.9±21.3 h in the 2nd group (р <0,05). The ICU length of stay between the groups did not differ and was 62±3 and 62±7 h, respectively (р >0,05).

CONCLUSION: Bilateral erector spinae plane block is a simple and safe method that induces analgesic effect and effect on homeostasis in acute pancreatitis, similar to epidural blockade. Further study of the role and location of erector spinae plane block in treating pain in acute pancreatitis is required.

Regional Anesthesia and Acute Pain Management. 2024;18(1):73-84
pages 73-84 views

Effectiveness of erector spinae plane block in children with pectus excavatum deformity during minimally invasive thoracoplasty with osteosynthesis of the sternocostal complex: a prospective randomized comparative study

Savenkov A.N., Ryzhikov D.V., Ivanov M.D., Vissarionov S.V., Koriachkin V.A., Pogorelchuk V.V., Zabolotskii D.V.

Abstract

BACKGROUND: Despite the widespread use of regional blocks in children, ensuring adequate perioperative pain control during minimally invasive thoracoplasty with osteosynthesis of the sternocostal complex remains a problem. The introduction of ultrasound navigation has allowed specialists to increasingly give preference to peripheral blockades; paravertebral anesthesia has proven to be effective in thoracic surgery. However, safer interfascial blocks, including erector spinae plane block, are rarely used in pediatrics, and there is no evidence base for the effectiveness of the method.

OBJECTIVE: Our aim was to compare the effectiveness of erector spinae plane block with paravertebral blockade during minimally invasive thoracoplasty with osteosynthesis of the sternocostal complex in children.

MATERIALS AND METHODS: A prospective randomized comparative study of children who underwent minimally invasive thoracoplasty with osteosynthesis of the sternocostal complex was conducted from September 2022 to April 2023. According to the inclusion criteria, the selected 39 children were divided into groups: I — paravertebral blockade, and II — erector spinae plane block. The mean arterial pressure, heart rate during the perioperative period stages, postanesthesia recovery by Aldrete scale and pain intensity by the Wong–Baker scale, and stress response markers (cortisol and lactate) were assessed.

RESULTS: No significant differences were observed in the study groups when comparing mean arterial pressure and heart rate at any of the measurement points of the perioperative period (p >0.05). Further, no significant differences were noted between the groups when comparing cortisol and lactate levels (p >0.05). The awakening level was characterized by a short recovery period and did not differ between the groups (p >0.05). The intensity of pain during the observation period did not exceed 5 points on the verbal rating scale in both groups, and the severity of pain was significantly higher in the group with blockade of the erector spinae plane block only 2 hours after surgery (p <0.05).Postoperative nausea and vomiting were more common in children with erector spinae plane block (p >0.05). No other adverse events were recorded.

CONCLUSION: Erector spinae plane block is an effective and simple method of regional anesthesia for minimally invasive thoracoplasty with osteosynthesis of the sternocostal complex and can be used as an alternative to paravertebral blockade in children.

Regional Anesthesia and Acute Pain Management. 2024;18(1):85-95
pages 85-95 views


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