Abstract in English:

Abstract Background Quadratus Lumborum Block (QLB) has recently become an effective analgesic regional technique frequently used in abdominal surgeries. However, due to the heterogeneity in studies regarding block approaches, a direct comparison of QLB types is needed. In this double-blind prospective randomized trial, we aimed to compare the effects of lateral and posterior approaches of QLB on pain and analgesic use in children undergoing orchiopexy. Methods Patients aged 6 months - 12 years undergoing elective unilateral open orchiopexy were included in the study. Patients were randomized into two groups using the closed-envelope method. Lateral or posterior QLB was applied under ultrasonography with 0.4 mL/kg 0.25% bupivacaine for both groups before the surgery. The primary outcome was the assessment of postoperative pain for 24 hours. Analgesic usage, parental satisfaction, and complications were recorded as secondary outcomes. Results Analyses were conducted on 80 patients. Both study groups achieved clinically adequate analgesia, and no significant pain score distinctions were observed within 24 hours (Total mean scores: FLACC [lateral QLB: 2.86 ± 4.69 vs. posterior QLB: 2.87 ± 3.71, p = 0.466], Wong-Baker [lateral QLB: 0.86 ± 2.03 vs. posterior QLB: 1.24 ± 1.85, p = 0.151]). No significant interaction effect between groups and postoperative time intervals on pain scores was observed (FLACC score p-interaction: 0.425, Wong-Baker score p-interaction: 0.451). There were no statistical differences in the number of patients necessitating intraoperative and postoperative analgesics. Parental satisfaction exhibited similarity between the groups, and no perioperative complications were observed in either group. Conclusion Lateral and posterior QLB provided similar perioperative analgesia in pediatric patients undergoing orchiopexy. Clinical trial registration number NCT05056038. Date of registration 02 June 2021.

Abstract in English:

Abstract Introduction Laparoscopic Cholecystectomy (LC) is a commonly performed surgical procedure. The pneumoperitoneum and the depth of Neuromuscular Blockade (NMB) may impact the occurrence of postoperative pain and the quality of recovery. Methods A randomized, double-blind, and prospective clinical trial with 124 patients undergoing LC, divided into 4 groups: SP/MB (Standard Pneumoperitoneum pressure and Moderate NMB); LP/MB (Low Pneumoperitoneum pressure and Moderate NMB); SP/DB (Standard Pneumoperitoneum pressure and Deep NMB); and LP/DB (Low Pneumoperitoneum pressure and Deep NMB). Recovery quality was assessed using the Quality of Recovery Questionnaire (QoR-40), and postoperative pain was evaluated using a Verbal Numerical Rating Scale (VNRS). Results No difference was observed between groups regarding the total QoR-40 score 24 hours after surgery (p = 0.903). Despite better surgical conditions (scored from 0 to 5) in the LP/DB group (4.7 ± 0.52) and lower in the LP/MB group (4.1 ± 0.95), the LP/DB group showed a longer stay in the Post-Anesthesia Care Unit (PACU), a higher need for rescue treatment for nausea and vomiting in the ward (p = 0.044), and greater resting pain at 24 hours (p = 0.027). Conclusion The use of different pneumoperitoneum pressures under moderate or deep neuromuscular blockade in patients undergoing Laparoscopic Cholecystectomy (LC) did not alter patients’ perception of postoperative recovery quality. The combination of standard pneumoperitoneum pressure with deep neuromuscular blockade was associated with a better perception of surgical field quality as evaluated by the surgeon.

Abstract in English:

Abstract Study objective To study the effect of Intravenous (IV) dexmedetomidine during spinal anesthesia on duration of sensory block and postoperative analgesia in patients undergoing lower limb orthopedic surgery. Design Prospective randomized double blind controlled trial. Intervention Patients in intervention (DX) group received 0.5 mcg.kg-1 IV dexmedetomidine over 10 min. Spinal anesthesia was administered and an infusion of dexmedetomidine 0.5 mcg.kg-1.h-1 was given throughout surgery. Measurements Onset time of sensory and motor block, maximum height of sensory block and duration of sensory and motor block were assessed. Intraoperative Heart Rate (HR), Blood Pressure (BP), Peripheral Oxygen Saturation (SpO2), sedation scores, postoperative pain scores, time to requirement of first analgesic and analgesic consumption over first 24h were noted. Results Data of 58 ASA I/II adults was analyzed. Duration of sensory block, defined as time to two-dermatome regression, was 137.03 ± 25.02 min in DX group and 79.45 ± 11.27 min in the NS group (p = 0.000). Onset of sensory and motor block and maximum height of sensory block were similar. Postoperative VAS scores were lower in the DX group at 4h and 24h (p = 0.001, p = 0.0001) and comparable at 0h, 8h and 12h. Time to requirement of postoperative analgesia was longer in the DX group (p < 0.001) and requirement of postoperative analgesics was higher in the NS group. Sedation scores and incidence of bradycardia were higher in the DX group, but hypotension was similar. Conclusion IV dexmedetomidine (0.5 mcg.kg-1 followed by 0.5 mcg.kg-1.h-1) resulted in extended sensory and motor block, prolonged postoperative analgesia and reduced postoperative analgesic consumption with minimal side effects.

Abstract in English:

Abstract Background Radical cystectomy remains the standard treatment for invasive bladder cancer, yet it carries significant anesthetic risks. While robot-assisted surgery has gained popularity, data comparing its anesthetic implications to those of open surgery are limited. This study aimed to compare the incidence of transoperative complications between the two techniques. Methods We retrospectively analyzed 44 patients who underwent open (n = 29) or robot-assisted (n = 15) radical cystectomy in a university hospital between 2019 and 2024. Data were collected on American Society of Anesthesiologists (ASA) physical status, intraoperative hemodynamic parameters, ventilatory complications, additional postoperative opioid requirements, Intensive Care Unit (ICU) stay, and total length of hospital stay. Correlations between blood loss, transfusion requirements, and hemodynamic variables were evaluated. Results The robotic cystectomy group experienced less intraoperative bleeding (mean of 410 ± 185 mL vs. 662.5 ± 210 mL; p = 0.002), but no significant reduction in transfusion requirements (95% CI not reported; p = 0.110) despite a strong correlation between bleeding volume and need for transfusion (r = 0.78; p < 0.001). Opioid consumption was significantly higher in the open cystectomy group (75.9% vs. 33.3%; p = 0.004). There was no significant difference in intraoperative hypotension, vasoactive drug use, ventilatory complications, in-hospital mortality, ICU stay, or total hospital stay (p > 0.05 for all). However, the small sample size limits the precision of these estimates. Conclusion While robot-assisted radical cystectomy was associated with reduced blood loss and lower additional postoperative opioid use, our small retrospective sample did not identify significant differences in intraoperative hemodynamic parameters or major complications. The surgical technique had no impact on in-hospital mortality.

Abstract in English:

ABSTRACT Background Preoperative anxiety in children is a known risk factor for Emergence Delirium (ED). The family environment may indirectly influence ED by modulating anxiety levels, but its direct role in ED remains unclear. The purpose of this study is to explore the associations between the occurrence of ED and family environmental factors in children. Identifying such associations may support the use of preoperative screening and targeted interventions to reduce ED risk. Methods In this prospective observational study, 334 children (3∼7 years) undergoing elective tonsillectomy/adenoidectomy were assessed. Preoperative visits recorded clinical data and used the Chinese Family Environment Scale (FES-CV) and State/Trait Anxiety Inventories (parental anxiety). Preoperative child anxiety was measured via modified Yale Preoperative Anxiety Scale (m-YPAS). ED was assessed postoperatively in PACU using the Pediatric Anesthesia Emergence Delirium scale (PAED ≥ 10). Results ED incidence was 21.9%. No significant association existed between overall home environment and ED. However, achievement orientation (FES-CV) negatively correlated with the m-YPAS score (m-YPAS; r = -0.139, p = 0.011). Independent ED risk factors identified: younger age (OR = 0.949, 95% CI 0.912∼0.988), introverted personality (OR = 0.393, 95% CI 0.184∼0.843), and higher postoperative pain (FLACC score; OR = 1.885, 95% CI 1.610∼2.208). Conclusion While no direct link between home environment and ED was found, the negative correlation between achievement orientation and preoperative anxiety suggests an indirect influence. Identifying high-risk children using factors like age, personality, and pain levels remains important for ED prevention.

Abstract in English:

Abstract Background Lower abdominal surgeries in the pediatric population are associated with significant post-operative pain. Regional anesthesia techniques including ilioinguinal nerve block, Transversus Abdominis Plane (TAP) block, and Quadratus Lumborum (QL) block have been explored for lower abdominal surgeries. This study compares the analgesic effect of three different approaches to quadratus lumborum block in pediatric patients undergoing lower abdominal surgeries. Methods This randomized controlled trial included 120 pediatric patients aged between 1 and 7 years, scheduled for lower abdominal surgery under general anesthesia. Patients were randomized into 3 groups. Patients of Group A received QL block via anterior approach, Group L received QL block via lateral approach, and Group P received QL block via posterior approach. A volume of 0.5 mL.kg-1 of 0.375% ropivacaine was injected unilaterally for QL block in all patients. The primary outcome was 24hr postoperative fentanyl consumption. Secondary outcomes included intraoperative fentanyl use, postoperative pain scores, time to rescue analgesia and parental satisfaction. Results Postoperative mean fentanyl consumption was significantly lower in Group A as compared to Group L (p < 0.001) and Group P (p < 0.011). Postoperative median FLACC scores were significantly lower (p < 0.05) in Group A in comparison to Group L and Group P in the early postoperative period. The parent satisfaction score was significantly higher (p < 0.05) in Group A. Conclusion Anterior approach to QL block reduces postoperative analgesic consumption and provides longer duration analgesia with better parental satisfaction scores in comparison to lateral and posterior approaches in pediatric patients undergoing lower abdominal surgeries.

Abstract in English:

Abstract Background Hypertonic saline and mannitol are widely used to improve brain relaxation during supratentorial mass surgeries. Although continuous administration of hypertonic saline is known to reduce intracranial pressure, it has not yet been evaluated in supratentorial mass surgeries. Methods After institutional ethical committee approval, 92 patients scheduled for supratentorial craniotomy with glioblastoma multiforme, metastasis and/or midline shift (> 0.5 cm) were enrolled into this prospective, randomized, and double-blind study. The patients received hypertonic saline 3 mL.kg-1 bolus, hypertonic saline infusion 20 mL.h-1 or 20 % mannitol 0.6 gr.kg-1 after head positioning. Brain relaxation score (1 = Perfectly relaxed, 2 = Satisfactorily relaxed, 3 = Firm brain and 4 = Bulging brain) was the primary outcome. Sodium and chlorine levels were the secondary outcomes. Postoperative brain edema and midline shift were assessed. Results After randomization, two patients were excluded from the study. Brain relaxation scores were higher with hypertonic saline bolus compared to mannitol (p = 0.047). The effect size between groups for brain relaxation score was 0.22. Hypertonic saline continuous infusion and mannitol were similar with respect to brain relaxation scores. Sodium and chlorine levels were lower in the mannitol group. Postoperative midline shift and edema were lower with continuous hypertonic saline compared to other groups (p = 0.001, p = 0.006). Conclusion Continuous infusion of 3 % hypertonic saline was associated with better relaxation scores in the intraoperative period and with lower incidences of edema/midline shift in the postoperative period of supratentorial mass surgeries with glioblastoma multiforme, metastasis and/or midline shift.

Abstract in English:

Abstract Background Deeply sedated children cannot provide feedback if an epidural needle traumatizes the Spinal Cord (SC). Knowing relevant structure depths may, therefore, improve safety. We aimed to determine the epidural margin of safety, i.e., distances from the Ligamentum Flavum (LF) and from the dura mater to the SC in pediatric patients measured (i) Perpendicular to the SC and (ii) Parallel to the spinous process (to approximate needle trajectory). Methods Retrospective review of pediatric (0‒12 years-old) T2-weighted sagittal MRI spine scans without spinal pathology. Three investigators independently measured distances from the ventral edge of the LF, and from the ventral edge of the dura mater to the SC at T5/T6, T9/T10, and L1/L2. All measurements were taken perpendicular to the SC and parallel to the angle of the spinous process of the inferior vertebra. Results 111 MRI scans [52 females, 0.08‒12 (median 7) years-old] were analyzed. The conus medullaris was identified superior to the L1 vertebra in 47 scans, requiring L1/L2 measurement exclusion. When all ages were combined, the largest median (range) depth [dura-mater-SC = 4.87 (2.30‒10.30) mm, LF-SC = 8.10 (4.57‒12.53) mm, measured perpendicular to the SC; and dura-mater-SC = 8.20 (3.75‒19.57) mm; LF-SC = 13.40 (5.50‒39.77) mm, measured at the angle parallel to the inferior spinous process] was at T5/T6. Conclusion Our results suggest that the margin of safety (dura-mater-SC distance and LF-SC distance) for performing epidurals in children may be greatest at the mid-thoracic spinal region. The measured ranges were very wide. Further studies are warranted to validate these findings in pediatric patients with other relevant “epidural placement” positions.

Abstract in English:

Abstract Objectives To compare Pectoserratus Plane Block (PSPB) and Erector Spinae Plane (ESP) block regarding perioperative opioid consumption and chronic pain risk among women undergoing elective mastectomy. Methods Single-blind (patients), randomized (1:1) trial. The primary outcome was the composite measure defined as the use of fentanyl intraoperatively or tramadol postoperatively. Secondary outcomes encompassed intraoperative hemodynamics, short (24h), medium (3 months) and long-term (6 months) postoperative pain intensity and complications. Results 99 patients were randomized (50 in the PSPB group and 49 in the ESP block group). Of these, 93 patients had complete data for the primary outcome. Use of either fentanyl or tramadol was required for 20 of 47 patients (43%) in the PSPB group and 28 of 46 patients (61%) in the ESP block group (Relative Risk [RR] 0.70, 95% Confidence interval [95% CI] 0.47‒1.05, p = 0.09). PSPB-treated patients had a lower risk of tramadol (RR = 0.31, 95% CI 0.12-0.77, p = 0.01) and dipyrone (RR = 0.60, 95% CI 0.39‒0.92, p = 0.02) consumption than ESP block-treated patients. PSPB lowered chronic pain risk at 3 months (RR = 0.66, 95% CI 0.47‒0.92, p = 0.02), with lower scores for the Short-Form McGill Pain Questionnaire (Mean Difference [MD] -2.55, 95% CI -4.31 to -0.78, p = 0.005) and the Douleur Neuropathique 4 Questions questionnaire (MD = -1.08, 95% CI -2.05 to -0.11, p = 0.03). By 6 months, pain outcomes were statistically comparable between groups. Hemodynamic variables and complications were comparable between groups. Conclusion PSPB and ESP block resulted in similar overall opioid consumption among women undergoing mastectomy. However, PSPB was associated with lower postoperative tramadol consumption.

Abstract in English:

Abstract Background Tracheal extubation after general anesthesia may cause hemodynamic and respiratory complications, with no established strategies to prevent them. We conducted a meta-analysis to evaluate the safety and efficacy of beta-blockers in patients undergoing tracheal extubation. Methods We searched the MEDLINE, EMBASE and CENTRAL databases for randomized controlled trials up to 2024 comparing beta-blockers to placebo in patients undergoing tracheal extubation. Primary outcome: cough intensity; secondary: bronchospasm, bucking, hypertension. Risk Ratios (RR) with 95% Confidence Intervals (95% CI) were computed. Leave-one-out sensitivity and meta-regression analyses were performed for outcomes with high heterogeneity. Results We included 31 randomized studies, comprising 1,803 patients, of whom 965 received beta-blockers. The risk of moderate/severe cough (RR = 0.21; 95% CI 0.13 to 0.34; p < 0.001; I2 = 0%) and hypertension (RR = 0.28; 95% CI 0.13 to 0.58; p < 0.001; I2 = 45%) was significantly lower in the beta-blockers group compared with the placebo group. There were no statistically significant differences between groups in the risk of bronchospasm (RR = 0.58; 95% CI 0.17 to 1.94; p = 0.375; I2 = 0%) or bucking (RR = 0.47; 95% CI 0.20 to 1.13; p = 0.093; I2 = 72%). Sensitivity analysis identified Mendonça (2023) as the main heterogeneity source in bucking. Conclusion Our study demonstrates that beta-blockers reduced moderate/severe cough and hypertension in patients undergoing tracheal extubation compared with placebo with no significant difference in the risk of bronchospasm and bucking. These findings suggest beta-blockers may be a valuable strategy for preventing peri-extubation hemodynamic instability and airway hyperresponsiveness. Prospero register CRD42024542103.

Abstract in English:

Abstract Background Ketamine is believed to reduce the incidence of emergence agitation in children after surgery. However, recent studies reported contradictory findings. Thus, the primary objective of this review and meta-analysis was to investigate the use of ketamine in the reduction of emergence agitation in children undergoing surgery or procedure. Methods MEDLINE, EMBASE and CENTRAL were systematically searched from their inception date until March 2024. Randomized controlled trials comparing intravenous ketamine and placebo in children were sought. Observational studies, editorial letters or case reports were excluded. Results Seventeen studies (1515 patients) were included. Children who received ketamine were reported to have a significantly lower incidence of emergence agitation (OR = 0.27, 95% Confidence Interval: 0.16 to 0.45, p < 0.00001, I2 = 61%, certainty of evidence: very low). As compared to placebo, the ketamine group had a significantly lower postoperative pain score (MD = -2.28, 95% Confidence Interval -3.68 to -0.87, p = 0.001, I2 = 91%, certainty of evidence: very low). However, no significant differences were observed in the incidence of postoperative nausea and vomiting, desaturation, and laryngospasm. Conclusion This meta-analysis highlights the potential benefits of ketamine in the reduction of emergence agitation in children undergoing surgery or diagnostic procedures. However, high degrees of heterogeneity and low certainty of evidence limit the recommendations of the routine use of ketamine in the prevention of emergence agitation in children. Further high-quality randomized controlled trials are warranted before routine use can be recommended. PROSPERO registration CRD42024523680.