Superior hypogastric nerve plexus (SHNP) block for pain management after minimally invasive gynecology surgeries: A prospective randomized controlled trial.

Agrawal N ，Singh P ，Goyal M ，Yadav G ，Shekhar S ... -  《-》

Effectiveness of Low-Volume Versus High-Volume Ropivacaine for Ultrasound-Guided Maxillary Nerve Block in Double-Jaw Surgery: A Randomized Non-inferiority Trial.

Ultrasound-guided maxillary nerve block (UGMNB) is applied in oral and maxillofacial surgery to improve perioperative analgesia, decrease the risk of postoperative nausea and vomiting, and enhance recovery. However, the optimum volume of ropivacaine used for UGMNB is undetermined. Thus, it was hypothesized that in patients undergoing double-jaw surgery, low- and high-volume ropivacaine reduces perioperative pain with similar efficacy. Adults undergoing double-jaw surgery were enrolled in a randomized non-inferiority trial to receive a bilateral single-injection UGMNB with 2 mL (low-volume [LV] group) or 5 mL (high-volume [HV] group) of 0.375% ropivacaine on each side. A visual analog scale (VAS) score for maxillary pain at 2 h postoperatively was taken as the primary outcome. VAS score for maxillary and mandibular pain at 2, 4, 6, 8, 12, 24, and 48 h postoperatively, hemodynamic changes intraoperatively, consumption of intraoperative opioids and sedatives, vasoactive medication use, extubation time, postoperative rescue analgesia, time to the first analgesia, postoperative nausea and vomiting and UGMNB-related complications within 48 h post-surgery were assessed as the secondary outcomes. Sixty-four adults were included. The maxillary pain score in the LV group was not inferior to that in the HV group at 2 h postoperatively, with a non-inferiority margin of 1 (mean difference - 0.1; 95% confidence interval [CI] - 0.6 to 0.8, P = 0.414 for non-inferiority). Maxillary and mandibular pain demonstrated no difference in the measured times between groups. The incidence of postoperative nausea was significantly higher in the LV group than that in the HV group at 6-24 h (12 (37.5%) vs. 5 (15.6%), P = 0.048). Moreover, no differences in intraoperative hemodynamic parameters, medications during anesthesia, time to extubation, rescue analgesia, time to the first analgesia, and postoperative vomiting were observed. Only one patient in the LV group was observed to have maxillary nerve block-related complications. To conclude, the efficacy of UGMNB with 2 mL of 0.375% ropivacaine has the same efficacy as the 5 mL drug in reducing perioperative pain in patients undergoing double-jaw surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Chen MK ，Zhao L ，Luo W ，Luo K ，Lin J ，Ji Y ... -  《-》

A single-blind randomized controlled trial of celiac plexus block for analgesia after whipple surgery.

Effective management of both incisional and visceral postoperative pain during open abdominal surgery is crucial for patient recovery. This study evaluated the effect of celiac plexus block on postoperative pain and recovery. This single-center, patient-assessor-blinded, blank-controlled randomized clinical trial was conducted from March 9, 2022, to November 12, 2023. A total of 78 patients scheduled for open Whipple surgery were randomized. The intervention involved either receiving a celiac plexus block (Group NB) with 20 ml of 0.5% ropivacaine during surgery or not receiving the block (Group GC). Both groups received traditional postoperative analgesia. The primary outcome was opioid consumption within 72 h post-surgery. Secondary outcomes included the frequency of analgesic pump presses, pain scores, hemodynamic parameters before and after nerve block as well as postoperatively, levels of postoperative inflammatory markers, time to first flatus, length of postoperative hospital stay, and perioperative complications. Among the 78 patients enrolled, 37 were randomized to receive intraoperative celiac plexus block and 41 were not. In total, 12 patients (8 in group GC and 4 in group NB) were excluded because of protocol deviations, and 66 patients (33 in each group) were included in the per-protocol analysis. Group NB demonstrated significantly lower total opioid consumption within the first 72 h post-surgery than group GC (mean (SD), 66 (18.8) mg vs. 88.9 (21.2) mg, respectively; P < 0.01). Pain scores assessed using the Visual Analog Scale were consistently lower in group NB at all postoperative time points (all P < 0.05). The first press of the patient-controlled analgesia (PCA) pump occurred significantly later, and the daily frequency of PCA pump presses was lower in group NB. The time to first flatus and length of postoperative stay were shorter in group NB but not statistically significant. Only inflammatory markers showed significantly lower C-reactive protein (CRP) levels in group NB at 24 h postoperatively. Hemodynamic monitoring results indicated that it had a minor impact. We confirmed that the direct-vision intraoperative celiac plexus block is a safe and effective procedure that significantly reduces postoperative opioid consumption and pain scores. Further studies with larger sample sizes are warranted to confirm these findings and explore long-term outcomes. Clinical Trial Registry Identifier: NCT05205720. Registered on January 25, 2022.

Li M ，Fang L ，Xing T ，Wang C ，Chen S ，Yu S ，Zhu J ... -  《BMC Anesthesiology》

The Impact of Preoperative Combined Pectoserratus and/or Interpectoral Plane (Pectoralis Type II) Blocks on Opioid Consumption, Pain, and Overall Benefit of Analgesia in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized, Co

Acute postoperative pain remains a major obstacle in minimally invasive cardiac surgery (MICS). Evidence of the analgesic benefit of chest wall blocks is limited. This study was designed to assess the influence of combined pectoserratus plane block plus interpectoral plane block (PSPB + IPPB) on postoperative pain and the overall benefit of analgesia compared with placebo. A prospective, randomized, triple-blinded study was conducted. The setting was the operating room and intensive care unit of a university hospital. A total of 60 patients undergoing elective right-lateral MICS were enrolled. Patients were randomly assigned to preoperative PSPB + IPPB with 30 mL of ropivacaine 0.5% or saline. The primary endpoint was total intravenous morphine milligram equivalents administered in the first 24 hours after extubation. Secondary endpoints included the Overall Benefit of Analgesia Score (OBAS) at 24 hours after extubation and repeated Visual Analogue Scale (VAS). Values for intravenous morphine milligram equivalents administered in the first 24 hours after extubation were significantly lower (median [interquartile range]: 4.2 mg [2.1 - 7.9] v 8.3 mg [4.2 - 15.7], p = 0.025; mean difference: 6.7 mg [0.94 - 12 mg], p = 0.024, Cohen's d: 0.64 [0.09 - 1.2]). Moreover, OBAS at 24 hours and VAS after extubation were significantly lower (4.0 [3.0 - 6.0] v 7.0 [3.0 - 9.0], p = 0.043; 0.0 cm [0.0 - 2.0] v 1.5 cm [0.3 - 3.0], p = 0.030). VAS did not differ between groups at later points. Preoperative PSPB + IPPB reduced 24-hour postextubation opioid consumption, pain at extubation, and OBAS. Given its low risk and expedient placement, it could be a helpful addition to MICS protocols. Future studies should evaluate these findings in multicenter settings and further elucidate the optimal timing of block placement.

Gasteiger L ，Fiala A ，Naegele F ，Gasteiger E ，Seisl A ，Bonaros N ，Mair P ，Velik-Salchner C ，Holfeld J ，Höfer D ，Stundner O ... -  《-》

Transversus abdominis plane (TAP) blocks for prevention of postoperative pain in women undergoing laparoscopic and robotic gynaecological surgery.

Pain control following laparoscopic gynaecologic surgery is key to successful recovery. The efficacy of the transversus abdominis plane (TAP) block compared to no block or a local anaesthetic injection has not been well established in this population. To evaluate the benefits and harms of single-shot transversus abdominis plane blocks for the prevention of postoperative pain in women undergoing laparoscopic and robotic gynaecological surgery compared to no block, sham block, or injection of local anaesthetic. We searched CENTRAL, MEDLINE, Embase, two trials registers, and handsearched abstracts to 6 December 2024. We included prospective randomised controlled trials (RCTs) of adult women undergoing minimally invasive gynaecologic surgery that compared single-shot TAP block to no block, sham block, or injection of local anaesthetic. We excluded studies that were non-randomised or of non-gynaecologic surgery. Critical and important outcomes: participant-reported pain intensity 24 hours following surgery (combined, at rest, and with movement), adverse events (serious adverse events, nausea and vomiting, postoperative sedation), opioid consumption 24 and 48 hours after surgery. Other outcomes: pain intensity 2, 6, 12, and 48 hours after surgery, opioid consumption intraoperatively, time from surgery to first participant requirement for postoperative opioid, time from surgery until discharge. We assessed the risk of bias with RoB 1. We conducted meta-analyses using random-effects models. We calculated mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes. We reported serious adverse events as described by the study authors. We summarised the certainty of evidence using GRADE methods. We included 21 RCTs with a total of 1645 participants. Studies were conducted in 10 countries, and published between 2011 and 2023. Six studies compared TAP block to no block, eight compared TAP block to an injection of local anaesthetic, and seven studies compared TAP block to sham block. Studies reported pain outcomes in various ways, so we made assumptions to allow us to combine data. 1. TAP block compared to no block TAP blocks may result in little or no difference in pain 24 hours after surgery for women undergoing laparoscopic or robotic gynaecologic procedures (MD -4.66, 95% confidence interval (CI) -11.06 to 1.74; 4 RCTs, 242 women; I2 = 88%; very low-certainty evidence). TAP blocks may result in little or no difference in pain at rest (MD -0.16, 95% CI -1.60 to 1.28; 2 RCTs, 146 women; I2 = 0%, low-certainty evidence), or pain with movement (MD -1.59, 95% CI -4.44 to 1.25; 2 RCTs, 146 women; I2 = 0%, low-certainty evidence) 24 hours after surgery. Two studies reported serious adverse events. None reported an event related to the TAP block (out of 50 women). TAP blocks may result in little or no difference in postoperative nausea and vomiting (RR 0.60, 95% CI 0.24 to 1.54; 2 RCTs, 111 women; I2 = 0%, low-certainty evidence). TAP blocks may have little or no effect on 0- to 24-hour postoperative morphine consumption (MD 3.08, 95% CI -3.71 to 9.88; 3 RCTs, 140 women; I2 = 70%; very low-certainty evidence). None of the studies reported 48-hour morphine consumption. 2. TAP block compared to local anaesthetic Women who received TAP blocks may experience a small reduction in 24-hour postoperative pain compared to local anaesthetic (MD -11.58, 95% CI -20.52 to -2.64; 6 RCTs, 393 women; I2 = 89%; low-certainty evidence). None of the studies reported pain at rest or with movement. Four studies reported serious adverse events. None reported an event related to the TAP block (out of 168 women). TAP block may result in little or no difference in postoperative nausea and vomiting compared to local anaesthetic (RR 0.63, 95% CI 0.34 to 1.15; 1 RCT, 62 women; low-certainty evidence). There may be little or no difference in opioid consumption 0 to 24 hours after surgery for women who received a TAP block compared to local anaesthetic (MD -8.21, 95% CI -19.69 to 3.27; 2 RCTs, 177 women; I2 = 81%; very low-certainty evidence). TAP block compared to local anaesthetic may result in little or no difference in opioid consumption 0 to 48 hours after surgery (MD -15.80, 95% CI -32.11 to 0.51; 1 RCT, 40 women; low-certainty evidence). 3. TAP block compared to sham block TAP block probably results in a small decrease in 24-hour postoperative pain compared to sham block (MD -14.26, 95% CI -27.03 to -1.48; 4 RCTs, 371 women; I2 = 98%; moderate-certainty evidence). None of the studies reported pain at rest. TAP block probably results in a small reduction in pain with movement 24 hours following surgery (MD -3.60, 95% CI -6.72 to -0.48; 1 RCT, 60 women; moderate-certainty evidence). Six studies reported serious adverse events. None reported an event related to the TAP block (out of 307 women). There may be little or no difference in postoperative nausea and vomiting between TAP and sham blocks (RR 0.68, 95% CI 0.45 to 1.03; 3 RCTs, 244 women; I2 = 0; low-certainty evidence). There may be little or no difference in 24-hour postoperative morphine consumption between TAP and sham blocks (MD -13.08, 95% CI -30.78 to 4.63; 5 RCTs, 310 women; I2 = 99%; low-certainty evidence). None of the studies reported 48-hour postoperative opioid consumption. Amongst women undergoing minimally invasive gynaecologic surgery, we did not find a clinically meaningful effect of TAP block on postoperative pain or opioid consumption. However, there may be a small reduction of pain using TAP blocks compared to local anaesthetic or sham blocks. The TAP block is probably safe, since no adverse events were noted amongst the 525 women who received a block, and for whom safety data were available. The evidence is limited by heterogeneity in the results, risk of bias in the studies, and assumptions made for synthesis when combining data. The review had no dedicated funding. Protocol (2022): DOI: 10.1002/14651858.CD015145.

Alsamman S ，Haas DM ，Patanwala I ，Klein DA ，Kasper K ，Pickett CM ... -  《Cochrane Database of Systematic Reviews》