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Regional Anesthesia and Pain Medicine Jan 2024Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are... (Review)
Review
BACKGROUND/IMPORTANCE
Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described.
OBJECTIVE
We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years).
EVIDENCE REVIEW
We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.
FINDINGS
Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold.
CONCLUSIONS
Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.
Topics: Humans; Child; Anesthetics, Local; Ropivacaine; Amides; Pain, Postoperative; Nerve Block; Bupivacaine; Catheters
PubMed: 37429620
DOI: 10.1136/rapm-2023-104666 -
Cureus Jul 2023Refractory hypertension is highly prevalent among the hypertensive population, and current clinical management has failed to provide optimal control for these... (Review)
Review
The Implementation of Renal Denervation in the Management of Resistant Hypertension Despite Use of Multitherapy Antihypertensives at Maximally Tolerated Doses: A Contemporary Literature Review.
Refractory hypertension is highly prevalent among the hypertensive population, and current clinical management has failed to provide optimal control for these individuals. This subtype of arterial hypertension is defined as a persistently elevated systolic blood pressure reading of 140 mmHg, or higher, despite multiple antihypertensive use at maximally tolerated dosing. These patients have an elevated risk of cardiovascular and renal complications, urging for the need of more effective therapeutic management. Renal sympathetic efferent nerves have been noted to play an important role in volume and blood pressure homeostasis. Before the implementation of oral antihypertensives, the use of surgical lumbar sympathectomy for the reduction of persistent hypertension was considered a life-saving approach. However, individuals were left with debilitating side effects, such as postural hypotension, syncope, and impotence. A new and minimally invasive technique has been proposed, where the kidneys undergo selective denervation in hopes of providing decreased cardiovascular morbidity and mortality for patients with resistant hypertension. Some studies demonstrated promising outcomes with a reduction in blood pressure, a decrease in medication reliance, and a potential long-lasting effect of the procedure with an overall improvement in cardiovascular health. Unfortunately, most of the available data was obtained from observational, uncontrolled studies with short-term follow-up, small sample sizes, and high variability in blood pressure measurement. Therefore, further evidence is needed to determine whether renal denervation provides long-term benefits for blood pressure control and improves outcomes for mortality and cardiovascular events in this patient population.
PubMed: 37559838
DOI: 10.7759/cureus.41598 -
Plastic and Reconstructive Surgery Jul 2024Denervation techniques have increased in popularity for treatment of primary knee osteoarthritis. However, few clinical trials have been conducted on surgical knee... (Clinical Trial)
Clinical Trial
BACKGROUND
Denervation techniques have increased in popularity for treatment of primary knee osteoarthritis. However, few clinical trials have been conducted on surgical knee denervation. This study was conducted to evaluate the safety and efficacy of a surgical denervation technique for the treatment of primary knee osteoarthritis.
METHODS
Patients were included in the trial if they had failed conservative management for osteoarthritis with corticosteroid injections and were not candidates for total knee arthroplasty. Patients were treated with a surgical knee denervation. Preoperative and postoperative scores were assessed to examine the improvement in pain, function, and quality of life.
RESULTS
Twenty-four knee denervation procedures were performed in 21 patients. The average follow-up time was 21 months, with a minimum follow-up of 12 months. Patients experienced an improvement in pain with a decrease in visual analogue scale pain scores from 8.7 to 2.9, an improvement in function with a decrease in Western Ontario McMaster Arthritis Score scores from 69 to 32, and an improvement in quality of life with an increase in European quality of life index from 0.183 to 0.646. A clinically significant improvement in pain occurred in 92% of patients, whereas 75% of patients had an improvement in function and 83% had an improvement in quality of life.
CONCLUSIONS
The treatment of recalcitrant knee pain in nonarthroplasty candidates is a difficult issue. This trial suggests that a surgical denervation technique provides improvement in pain, function, and quality of life. Surgical denervation may be a beneficial treatment for patients with recalcitrant pain from primary knee osteoarthritis.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, IV.
Topics: Humans; Osteoarthritis, Knee; Female; Male; Middle Aged; Denervation; Aged; Quality of Life; Pain Measurement; Treatment Outcome; Follow-Up Studies; Arthralgia; Knee Joint
PubMed: 37678253
DOI: 10.1097/PRS.0000000000011020 -
Pain Physician Sep 2023One of the common neuraxial anesthesia complications is postdural puncture headache (PDPH). Greater occipital nerve block (GONB) is a simple and safe maneuver with a... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
One of the common neuraxial anesthesia complications is postdural puncture headache (PDPH). Greater occipital nerve block (GONB) is a simple and safe maneuver with a faster onset than other treatment modalities.
OBJECTIVES
Our work aims to compare the pain-relieving effect between distal and proximal ultrasound (US)-guided bilateral GONBs for PDPH.
STUDY DESIGN
A randomized, double-blinded study.
SETTING
Aswan University Hospital, Egypt.
METHODS
The study included 50 patients of both genders, aged 20 to 60 years, who had PDPH with a sitting Numeric Rating Scale (NRS-11) >= 4. Patients were randomized into 2 equal groups. Group D received a US-guided distal bilateral GONB (at the superior nuchal line level). Group P received a US-guided proximal bilateral GONB (at the second cervical vertebra level). Three milliliters of isobaric bupivacaine 0.5% and 4 mg dexamethasone were injected in both blocks.
RESULTS
There was a significant decrease in lying down and sitting NRS-11 at 10 minutes, 6, 12, 24, 36, and 48 hours after the intervention compared to before the intervention in both groups. Only sitting NRS-11 was significantly lower in group P than group D in all measurements after the intervention. Success rate (sitting NRS-11 < 4) at 24 hours was 60% in group D and 84% in group P, with an insignificant difference. The total 48-hour paracetamol and tramadol consumption was significantly lower in group P than in group D (P = 0.038 and 0.036, respectively). Transient cervicalgia occurred in 8% of each group.
LIMITATIONS
The small number of cases to prove the secondary outcomes and the absence of a control group.
CONCLUSIONS
US-guided proximal and distal GONBs were minimally invasive, simple, and effective ways to treat PDPH, with the superiority of proximal GONB in alleviating PDPH.
KEY WORDS
Postdural puncture headache, distal, proximal, greater occipital nerve, block, ultrasound, pain-relieving, neuraxial anesthesia.
Topics: Humans; Male; Female; Post-Dural Puncture Headache; Bupivacaine; Peripheral Nerves; Pain; Nerve Block
PubMed: 37774204
DOI: No ID Found -
SN Comprehensive Clinical Medicine 2024Arterial hypertension is one of the most significant and prevalent risk factors for cardiovascular disease. Despite widespread awareness of the condition, as well as a... (Review)
Review
Arterial hypertension is one of the most significant and prevalent risk factors for cardiovascular disease. Despite widespread awareness of the condition, as well as a multitude of available antihypertensive drug classes, rates of uncontrolled hypertension remain high on a global scale. Frequently, poor compliance with anti-hypertensive medication plays a big role in patients' inability to attain adequate blood pressure control. In individuals with resistant and/or uncontrolled hypertension, renal denervation is an emerging device-based therapy that has shown to be efficacious and safe in reducing blood pressure in several sham controlled trials. Additionally, it represents a treatment option for patients intolerant to oral pharmacotherapy. University Hospital Galway has been performing renal denervation procedures over the past number of years within multicentre, international sham-controlled trials and registries. Representing a novel and emerging antihypertensive treatment option, sources of referral for renal denervation are diverse and multiple; thus, there is an unmet need for standardised referral structures in Ireland. Herein, we review current and developing referral pathways for renal denervation at our institution, and discuss streamlined patient management and requirements to establish a centre of excellence.
PubMed: 38500967
DOI: 10.1007/s42399-024-01647-9 -
Aging Cell Jun 2024With aging skeletal muscle fibers undergo repeating cycles of denervation and reinnervation. In approximately the 8th decade of life reinnervation no longer keeps pace,...
With aging skeletal muscle fibers undergo repeating cycles of denervation and reinnervation. In approximately the 8th decade of life reinnervation no longer keeps pace, resulting in the accumulation of persistently denervated muscle fibers that in turn cause an acceleration of muscle dysfunction. The significance of denervation in important clinical outcomes with aging is poorly studied. The Study of Muscle, Mobility, and Aging (SOMMA) is a large cohort study with the primary objective to assess how aging muscle biology impacts clinically important traits. Using transcriptomics data from vastus lateralis muscle biopsies in 575 participants we have selected 49 denervation-responsive genes to provide insights to the burden of denervation in SOMMA, to test the hypothesis that greater expression of denervation-responsive genes negatively associates with SOMMA participant traits that included time to walk 400 meters, fitness (VO), maximal mitochondrial respiration, muscle mass and volume, and leg muscle strength and power. Consistent with our hypothesis, increased transcript levels of: a calciumdependent intercellular adhesion glycoprotein (CDH15), acetylcholine receptor subunits (CHRNA1, CHRND, CHRNE), a glycoprotein promoting reinnervation (NCAM1), a transcription factor regulating aspects of muscle organization (RUNX1), and a sodium channel (SCN5A) were each negatively associated with at least 3 of these traits. VO and maximal respiration had the strongest negative associations with 15 and 19 denervation-responsive genes, respectively. In conclusion, the abundance of denervationresponsive gene transcripts is a significant determinant of muscle and mobility outcomes in aging humans, supporting the imperative to identify new treatment strategies to restore innervation in advanced age.
Topics: Humans; Aging; Male; Muscle, Skeletal; Aged; Female; Middle Aged; Cohort Studies; Adult
PubMed: 38831622
DOI: 10.1111/acel.14115 -
Medicine Sep 2023As strong analgesics, opioids provide the analgesic component of general anesthesia, but they have bidirectional effects on the immune system, promoting the production... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
As strong analgesics, opioids provide the analgesic component of general anesthesia, but they have bidirectional effects on the immune system, promoting the production of pro-inflammatory factors. The idea of opioid-free anesthesia is to replace the analgesic effect of opioids in the treatment of acute pain with comparably effective drugs that do not affect the immune system and thereby decrease the production of inflammatory factors. Therefore, this study aims to observe the effect of opioid-free esketamine anesthesia based on quadratus lumborum block on inflammatory factors in patients undergoing lower abdominal or pelvic surgery.
METHODS
A total of 122 patients who underwent lower abdominal or pelvic surgery in our hospital from March 2021 to June 2022 were selected and divided into the esketamine (E) group (n = 62) and control (C) group (n = 60) according to the random number table method. According to the surgical field, the 2 groups underwent unilateral/bilateral quadratus lumborum block in the supine position under ultrasound guidance. In addition, both groups received a target controlled infusion of propofol 3 to 3.5 μg/mL and intravenous rocuronium 0.8 mg/kg. Group E was given opioid-free anesthesia, group C was given opioid-based anesthesia. A 3 to 5 laryngeal mask was inserted according to body weight, and rocuronium 0.5 mg/kg was added intermittently. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), C-reactive protein (CRP), procalcitonin, tumor necrosis factor-α (TNF-α), numeric rating scales, dosage of propofol, dexmedetomidine and rocuronium, as well as the numeric rating scales score and analgesic complications were monitored in the 2 groups.
RESULTS
There was no significant differences in general outcomes between the 2 groups (P > .05). The blood pressure in group E was higher than in group C at T1 (P < .05). The levels of IL-6, TNF-α, CRP and IL-8 in group E were significantly lower than in group C at T1, T2, T3, and T4 (P < .05). The levels of IL-6, TNF-α, procalcitonin, CRP and IL-8 in the 2 groups at T1, T2, T3, and T4 were significantly higher than at T0 (P < .05).
CONCLUSION
Opioid-free esketamine anesthesia based on quadratus lumborum block achieved perfect postoperative analgesia with little effect on inflammatory factors in patients undergoing lower abdominal or pelvic surgery.
Topics: Humans; Analgesics, Opioid; Interleukin-8; Interleukin-6; Procalcitonin; Propofol; Rocuronium; Tumor Necrosis Factor-alpha; Nerve Block; C-Reactive Protein
PubMed: 37713895
DOI: 10.1097/MD.0000000000034975 -
Journal of Clinical Anesthesia Sep 2023This systematic review and meta-analysis aimed to assess the superiority of airway nerve blocks versus airway anesthesia without nerve blocks for awake tracheal... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
This systematic review and meta-analysis aimed to assess the superiority of airway nerve blocks versus airway anesthesia without nerve blocks for awake tracheal intubation (ATI).
DESIGN
Systematic review and meta-analysis of randomized controlled trials (RCTs).
SETTING
All studies that assessed the superiority of airway anesthesia technique for awake tracheal intubation were searched in PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase and Chinese databases (including China National Knowledge Infrastructure, Wanfang database, and VIP databases) and trial registry databases from their inception to December 2022.
PATIENTS
Adult patients included in randomized controlled trials comparing airway anesthesia with or without airway nerve blocks for ATI.
INTERVENTIONS
Airway nerve (including superior laryngeal nerve, glossopharyngeal nerve, or recurrent laryngeal nerve) blocks for ATI.
MEASUREMENTS
The primary outcome was the intubation time. Secondary outcomes were quality of intubating conditions (including patient reaction to placement of the flexible scope and tracheal tube, coughing and gagging, and patient satisfaction) and overall complications during ATI.
MAIN RESULTS
Fourteen articles with 658 patients were identified for analysis. When compared with airway anesthesia without nerve blocks, airway nerve blocks significantly reduced intubation time (standardized mean difference [SMD] -2.57, 95% CI -3.59- -1.56, p < 0.00001), improved anesthesia quality of ATI with higher no reaction to placement of the flexible scope and tracheal tube (relative risk [RR] 9.87; 95% CI 4.10-23.75, p < 0.00001), lower cough or gag reflex during intubation (RR 0.35, 95% CI 0.27-0.46, p < 0.00001), higher excellent patient satisfaction rate (RR 1.88, 95% CI 1.05-3.34, p = 0.03), and lower overall complications (RR 0.29, 95% CI 0.19-0.45, p < 0.00001). The overall quality of evidence was moderate.
CONCLUSIONS
Based on current published evidence, airway nerve blocks provide better airway anesthesia quality for ATI with a shorter intubation time, better intubation conditions including higher no reaction to placement of the flexible scope and tracheal tube, lower cough or gag reflex during intubation, higher excellent patient satisfaction, and lower overall complications.
Topics: Adult; Humans; Cough; Wakefulness; Anesthesia, General; Intubation, Intratracheal; Nerve Block
PubMed: 37054484
DOI: 10.1016/j.jclinane.2023.111122 -
Trials Jan 2024Laparoscopic nephrectomy is a commonly utilized surgical approach for the management of renal cancer. Despite its widespread acceptance, postoperative pain management... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Laparoscopic nephrectomy is a commonly utilized surgical approach for the management of renal cancer. Despite its widespread acceptance, postoperative pain management remains a significant challenge for many patients undergoing this procedure. Traditional pain management techniques, including opioid and nonsteroidal anti-inflammatory drug administration, may not provide adequate pain relief and may result in adverse effects. In recent years, erector spinae plane block (ESPB) has emerged as a promising regional anesthesia technique due to its simplicity, safety, and potential efficacy in reducing postoperative pain. ESPB has demonstrated effectiveness in reducing postoperative pain in various surgical procedures. However, the efficacy of ESPB in laparoscopic nephrectomy for renal cancer has not been extensively studied. As such, further investigation is necessary to determine the potential benefits of ESPB in this context. The addition of adjuvants such as dexmedetomidine and dexamethasone to nerve blocks has been shown to improve both the duration and quality of the block. Multiple studies have demonstrated the safety and efficacy of these adjuvants in reducing postoperative pain and opioid consumption and improving patient satisfaction. The use of dexmedetomidine and dexamethasone as adjuvants for nerve blocks represents a promising approach for enhancing regional anesthesia and analgesia. In light of these findings, we have incorporated dexmedetomidine and dexamethasone into our nerve block protocol.
METHODS
This study is a randomized controlled trial conducted at a single center, with 50 participants being randomized in a 1:1 ratio to either the ESPB group or the control group. The trial aims to investigate the efficacy of ESPB in patients diagnosed with kidney cancer who are scheduled for laparoscopic nephrectomy. The primary outcome measure is the total consumption of intraoperative sufentanil. Secondary outcomes include the VAS score at rest and during coughing at 1 h, 6 h, 12 h, 24 h, and 48 h after surgery; total intraoperative remifentanil consumption; the number of times rescue analgesia is required; and the incidence of nausea and vomiting in the first 24 h after surgery. This study is registered for a duration of 1 year and is being conducted in China.
DISCUSSION
The objective of our study is to evaluate the potential benefits of erector spinae plane block (ESPB) in patients undergoing laparoscopic nephrectomy, with a focus on the impact of dexmedetomidine and dexamethasone as adjuvants on the quality and duration of the block, as well as postoperative pain and opioid consumption. By investigating the effects of these adjuvants in the context of ESPB, we hope to contribute to the growing body of literature on the use of adjuvants in nerve blocks and provide further insight into the potential benefits of this approach for improving patient outcomes following laparoscopic nephrectomy. This trial was approved by the Ethics Committee of the Second Affiliated Hospital of Army Medical University.
TRIAL REGISTRATION
China Clinical Trial Register ChiCTR2300068578 . Registered on 20 February 2023.
Topics: Humans; Analgesics, Opioid; Dexmedetomidine; Nephrectomy; Anesthesia, Conduction; Nerve Block; Pain, Postoperative; Adjuvants, Immunologic; Carcinoma, Renal Cell; Kidney Neoplasms; Analgesia; Laparoscopy; Ultrasonography, Interventional; Dexamethasone
PubMed: 38167138
DOI: 10.1186/s13063-023-07866-0 -
BMJ Open Sep 2023A major issue confronting clinicians treating hypertension in pregnancy is the limited number of pharmacological options. Endovascular catheter-based renal denervation...
Endovascular ultrasound renal denervation to lower blood pressure in young hypertensive women planning pregnancy: study protocol for a multicentre randomised, blinded and sham controlled proof of concept study.
INTRODUCTION
A major issue confronting clinicians treating hypertension in pregnancy is the limited number of pharmacological options. Endovascular catheter-based renal denervation (RDN) is a new method to lower blood pressure (BP) in patients with hypertension by reducing the activity of the renal sympathetic nervous system. Drugs that affect this system are safe in pregnant women. So there is reasonable evidence that RDN performed before pregnancy should not have deleterious effects for the fetus. Because the efficacy of RDN may be greater in younger patients and in women, we may expect a larger proportion of BP normalisation in young hypertensive women, but this remains to be proven. Our primary objective is to quantify the proportion of BP normalisation with RDN in this population.
METHODS AND ANALYSIS
WHY-RDN is a multicentre randomised sham-controlled trial conducted in six French hypertension centres that will include 80 women with essential hypertension treated or untreated, who are planning a pregnancy in the next 2 years and will be randomly assigned to RDN or classic renal arteriography and sham RDN in a ratio of 1:1. The primary outcome is the normalisation of 24-hour BP (<130/80 mm Hg) at 2-month post procedure off treatment. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected responder rates of 24% and 3% in the treatment and control group, respectively. Secondary outcomes include the absence of adverse outcomes for a future pregnancy, the variations of BP in ambulatory and home BP measurements and the evaluation of treatment prescribed.
ETHICS AND DISSEMINATION
WHY-RDN has been approved by the French Ethics Committee (Tours, Region Centre, Ouest 1- number 2021T1-28 HPS). This project is being carried out in accordance with national and international guidelines. The findings of this study will be disseminated by publication.
TRIAL REGISTRATION NUMBER
ClinicalTrials.gov, NCT05563337.
Topics: Pregnancy; Humans; Female; Blood Pressure; Proof of Concept Study; Hypertension; Kidney; Denervation; Treatment Outcome; Antihypertensive Agents; Randomized Controlled Trials as Topic; Multicenter Studies as Topic
PubMed: 37775290
DOI: 10.1136/bmjopen-2022-071164