BACKGROUND: Regional anaesthesia techniques, including the erector spinae fascial plane (ESP) block, reduce postoperative pain after video-assisted thoracoscopic surgery (VATS). Fascial plane blocks rely on spread of local anaesthetic between muscle layers, and thus, intermittent boluses might increase their clinical effectiveness. We tested the hypothesis that postoperative ESP analgesia with a programmed intermittent bolus (PIB) regimen is better than a continuous infusion (CI) regimen in terms of quality of recovery after VATS.
METHODS: We undertook a prospective, double-blinded, randomised, controlled trial involving 60 patients undergoing VATS. All participants received ESP block catheters and were randomly assigned to CI or PIB of local anaesthetic regimen for postoperative analgesia. The primary outcome was Quality of Recovery-15 (QoR-15) score 24 h after surgery. Secondary outcomes included postoperative respiratory function, opioid consumption, verbal rating pain score, time to first mobilisation, nausea, vomiting, and length of hospital stay.
RESULTS: Overall QoR-15 scores at 24 h after VATS were similar (PIB 115.5 [interquartile range 107-125] vs CI 110 [93-128]; Δ<6, P=0.29). The only quality of recovery descriptor showing a significant difference was nausea and vomiting, which was favourable in the PIB group (10 [10-10] vs 10 [7-10]; P=0.03). Requirement for rescue antiemetics up to 24 h after surgery was lower in the PIB group (4 [14%] vs 11 [41%]; P=0.04). There were no differences in other secondary outcomes between groups.
CONCLUSIONS: Delivering ESP block analgesia after VATS via a PIB regimen resulted in similar QoR-15 at 24 h compared with a CI regimen.

Background Pain after breast surgery has been described as moderate to severe in intensity and, if inadequately treated, increases postoperative morbidity, hospital cost, and the incidence of persistent postoperative pain. Serratus anterior plane (SAP) block is an interfascial injection technique for analgesia of the chest wall. There is a lack of data with regard to its analgesic and possible opioid-sparing effects in Sub-Saharan Africa. This study aimed to determine the perioperative analgesic effect of serratus anterior plane block administered for breast surgery. Methods This was a prospective, randomized, double-blinded study involving 52 patients and was randomized into the intervention (n = 26) and control (n = 26) groups. One patient in the control group did not receive the allocated intervention, while one in the intervention group lost to follow-up. Complete data of 50 participants, comprising intervention (n=25), was used in the analysis. Patients\' demographic and health characteristics, pre-induction, intra-operative, and postoperative hemodynamic parameters were noted. After induction of anesthesia, a blinded anesthetist performed an ultrasound-guided serratus anterior plane block with 0.25% plain bupivacaine or a sham block using 0.9% normal saline (control). Numerical rating scale (NRS) score and incidence of postoperative nausea and vomiting (PONV) were recorded immediately after surgery and at 1, 4, 8, and 24 postoperative hours. Patient satisfaction with analgesic management within the first 24 postoperative hours was also assessed. Results Patients who received SAP block had lower NRS scores at all measured time points, but this was only statistically significant at the fourth postoperative hour (p-value = 0.002). Compared to controls, patients who received SAP had lower intraoperative (11.3±1.5 mg vs. 11.9±1.5 mg, p value = 0.131) and postoperative (4.6±5.7mg vs. 10.5±6 mg, p value=0.001) mean opioid consumption. However, only the reduction in postoperative opioid consumption was found to be statistically significant. Most participants (> 90%) in this study did not experience PONV and were very satisfied with their postoperative pain management. Conclusion Serratus anterior plane block reduces NRS pain scores postoperatively. It also significantly reduces postoperative opioid consumption but does not significantly reduce intraoperative opioid consumption.

BACKGROUND: Peripheral nerve blocks may provide better conditions for closed reduction of distal radius fractures as compared to other more frequently used modalities. In this systematic review, we evaluate existing evidence on the effect and harm of peripheral nerve blocks for closed reduction of distal radius fractures in adults.
METHODS: We performed a systematic review with meta-analysis and trial sequential analysis including trials investigating the use of peripheral nerve blocks for closed reduction of distal radius fractures. Co-primary outcomes were (1) the quality of the closed reduction measured as the proportion of participants needing surgery afterwards and (2) pain during closed reduction.
RESULTS: Six trials (n = 312) met the inclusion criteria. One trial reported on the need for surgery with 4 of 25 participants receiving nerve block compared to 7 of 25 receiving haematoma block needing surgery (RR 0.57, 96.7% CI [0.19; 1.71], p = .50). Four trials reported pain during closed reduction. In a meta-analysis, pain was not statistically significantly reduced with a nerve block (-2.1 Numeric Rating Scale (NRS) points (0-10), 96.7% CI [-4.4; 0.2], p = .07, tau2 = 5.4, I2 = 97%, TSA-adj. 95% CI [-11.5; 7.3]). No trial sequential boundaries were crossed, and the required information size was not met. Pre-planned subgroup analysis on trials evaluating ultrasound guided peripheral nerve blocks (patients = 110) showed a significant decrease in \'pain during reduction\' (-4.1 NRS, 96.7% CI [-5.5; -2.6], p < .01, tau2 = 0.9, I2 = 80%). All trial results were at high risk of bias and the certainty of the evidence was very low.
CONCLUSIONS: The certainty of evidence on the effect of peripheral nerve blocks for closed reduction of distal radius fractures is currently very low. Peripheral nerve blocks performed with ultrasound guidance may potentially reduce pain during closed reduction. High-quality clinical trials are warranted.

BACKGROUND: A costoclavicular brachial plexus block is an emerging infraclavicular approach that targets the cords lateral to the axillary artery, providing rapid onset of sensory-motor blockade. However, the incidence of hemi-diaphragmatic paralysis (HDP), a potential complication, remains unclear compared to the widely used supraclavicular (SC) approach. This study aimed to compare the incidence of HDP between ultrasound-guided costoclavicular and SC brachial plexus blocks.
OBJECTIVE: To compare the influence of ultrasound-guided SC and costoclavicular brachial plexus blocks on diaphragmatic excursion, thickness, and contractility along with pulmonary function.
METHODS:  This prospective, randomized, observer-blinded controlled trial included 60 patients undergoing below-shoulder surgeries. Patients were randomized to receive either ultrasound-guided SC (Group S) or costoclavicular (Group C) brachial plexus block with 0.5% levobupivacaine. The diaphragmatic function was assessed using ultrasonographic evaluation of diaphragm thickness and diaphragmatic thickness fraction (DTF) pre- and postblock. Pulmonary function tests (PFTs) (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow rate (PEFR)) were performed preblock and two hours postblock. Block characteristics were compared.
RESULTS: The SC group exhibited a significantly larger reduction in DTF from preblock to postblock compared to the costoclavicular group (mean ΔDTF: 34.38% vs. 14.01%, p<0.01). Both groups showed significant declines in FVC, FEV1, and PEFR postblock, but the magnitude of deterioration was significantly greater in the SC group, displaying no significant difference in block characteristics.
CONCLUSIONS: The costoclavicular brachial plexus block demonstrated superior preservation of diaphragmatic contractility and lesser deterioration of PFTs compared to the SC approach while being equally effective. These findings highlight the potential benefits of the costoclavicular technique in minimizing diaphragmatic dysfunction and respiratory impairment, particularly in patients at risk for respiratory complications.

The trigeminal nerve is responsible for innervating the periorbita. Ultrasound-guided trigeminal block is employed in humans for trigeminal neuralgia or periorbital surgery. There are no studies evaluating this block in dogs. This study aims to evaluate and compare two approaches (coronoid and temporal) of the trigeminal nerve block. We hypothesised superior staining with the coronoid approach. Thirteen dog heads were used. After a preliminary anatomical study, two ultrasound-guided injections per head (right and left, coronoid and temporal approach, randomly assigned), with an injectate volume of 0.15 mL cm-1 of cranial length, were performed (iodinated contrast and tissue dye mixture). The ultrasound probe was placed over the temporal region, visualising the pterygopalatine fossa. For the temporal approach, the needle was advanced from the medial aspect of the temporal region in a dorsoventral direction. For the coronoid approach, it was advanced ventral to the zygomatic arch in a lateromedial direction. CT scans and dissections were conducted to assess and compare the position of the needle, the spread of the injectate, and nerve staining. No significant differences were found. Both approaches demonstrated the effective interfascial distribution of the injectate, with some minimal intracranial spread. Although the coronoid approach did not yield superior staining as hypothesised, it presents a viable alternative to the temporal approach. Studies in live animals are warranted to evaluate clinical efficacy and safety.

OBJECTIVE: We previously designed and validated a virtual reality-based simulator to help train novices in ultrasound-guided needling skills necessary for safe and competent ultrasound-guided regional anaesthesia. This study was designed to compare the performance and error rates of novices trained by a human faculty aided with the assistance of this virtual reality simulator (virtual reality-assisted training), versus novices trained wholly by humans (conventional training).
METHODS: In this single centre, randomised controlled study, we used a standardised teaching protocol, rigorous blinding, iterative training of assessors, and validated global rating scale and composite error score checklists to assess skills learning of novice participants.
RESULTS: We recruited 45 novices and scored 270 assessments of performance and error rates. Inter-rater correlation coefficient of reliability of scoring between assessors for the global rating scale was 0.84 (95%CI 0.68-0.92) and for the composite error score checklist was 0.87 (95%CI 0.73-0.93). After adjustment for age, sex, Depression, Anxiety and Stress-21, and baseline score, there was no statistical difference for virtual reality-assisted training compared to conventional training in final global rating score (average treatment effect -3.30 (95%CI-13.07-6.48), p = 0.51) or in the final composite error score (average treatment effect 1.14 (95%CI -0.60-2.88), p = 0.20). Realism in the virtual reality simulator was similar to real-life when measured by the Presence Questionnaire, all components p > 0.79; and task workload assessed by the NASA-Task Load Index was not statistically different between groups, average treatment effect 5.02 (95%CI -3.51-13.54), p = 0.25. Results were achieved in the virtual reality-assisted group with half the human faculty involvement.
CONCLUSIONS: Novices trained using a hybrid, virtual reality-assisted teaching program showed no superiority to novices trained using a conventional teaching program, but with less burden on teaching resources.

We investigated the distribution of injected dye after deep serratus anterior plane and superficial parasternal intercostal plane blocks in 15 Thiel embalmed cadavers. We injected 0.4 ml.kg-1 of 0.25% aqueous methylene blue solution into the deep serratus anterior and superficial parasternal intercostal planes using real-time ultrasound needle visualisation followed by posterior dissection to observe the distribution of the injected dye in the chest wall. The two blocks were performed bilaterally in 15 cadavers at the T5/T6 level, comprising 60 blocks in 30 hemithoraces in total. At dissection, the intercostal nerve territories were observed to be dyed completely from T2 to T6 in 28 of 30 hemithoraces, and extending caudal to T6 in 10 hemithoraces. Following the deep serratus anterior plane blocks in all cadavers, the dye was found to have spread to the axillae. Following the superficial parasternal intercostal plane blocks, the dye reached T7 in four cadaver dissections. We concluded that the territories innervated by the intercostal nerves (T2-T6 dermatomes) are dyed following the combination of the two blocks when performed at the T5-T6 intercostal space level. These techniques might provide an effective option for anaesthesia in breast surgery.

BACKGROUND: Hip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy.
METHODS: Consenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness.
RESULTS: There were no significant differences in 24-h opioid consumption (block vs sham block, mean difference -3.2 mg oral morphine equivalent, 95% confidence interval -15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes.
CONCLUSIONS: In patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day.
BACKGROUND: www.
RESULTS: gov (NCT03069183).

BACKGROUND: Previous studies have shown that ultrasound guided costoclavicular block may require a double shot to provide adequate, rapid sensory and motor blockade. In this trial, we hypothesized that if the corner pocket approach (between axillary artery and median cord) is used instead of the central approach (at the midpoint of the 3 cords) when performing single-shot costoclavicular block, the onset of blockade would be non-inferior to the double-shot technique.
METHODS: Ninety patients undergoing upper limb surgery were randomized to 2 groups for ultrasound-guided costoclavicular block (CCB) at a tertiary hospital. One group received ultrasound guided single-shot CCB using the corner pocket approach and other received ultrasound guided double-shot - the first shot at the centre of the 3 cords and the second between the axillary artery and the median cord. An observer blinded to group assignment recorded blockade onset time (defined as the time required to achieve a minimal sensorimotor composite score of 14 out of 16 points).
RESULTS: Of the 101 patients assessed for eligibility, 90 were recruited over period of 1 year (February 2022 to January 2023), with 45 in each group. Onset time was 22.1 ± 3.1 min in the single-shot group and 22.4 ± 2.9 min in the double-shot group. This difference was insignificant (P = .3).
CONCLUSIONS: Time to onset of blockade and full anaesthesia are similar in single-shot corner pocket CCB vs double-shot CCB. Further studies are required to determine the minimum effective volume of local anaesthetic required for the described technique.

OBJECTIVE: To compare the perioperative cumulative opioid consumption and the incidence of cardiovascular complications in dogs undergoing hemilaminectomy in which either an erector spinae plane (ESP) block or systemic opioids were administered.
METHODS: Prospective randomized clinical trial.
METHODS: A total of 60 client-owned dogs.
METHODS: Dogs were randomized to one of three groups: an ESP block (group ESP), a constant rate infusion of fentanyl (group FNT, positive control) or a single dose of methadone as premedication (group MTD, negative control). Intraoperative nociceptive response was treated with fentanyl [1 μg kg-1, intravenously (IV)] boli. Before closure of the surgical site, morphine (0.1 mg kg-1) was applied to the dura mater. The cumulative dose of opioids was recorded and compared between groups. The incidence of intraoperative bradycardia and/or hypotension and the time to extubation were compared between groups. The short form of the Glasgow Composite Pain Scale (SF-GCPS) was used to score nociception before anaesthetic induction and 1, 2, 6, 12,18 and 24 hours postoperatively. Methadone 0.2 mg kg-1 was administered IV if the SF-GCPS score was ≥ 5.
RESULTS: Group MTD required more intraoperative rescue analgesia than groups ESP (p = 0.008) and FNT (p = 0.001). The total cumulative intraoperative dose of fentanyl was higher in groups FNT (p < 0.0001) and MTD (p = 0.002) than in group ESP. The incidence of cardiovascular complications was similar between groups. Extubation time was longer in group MTD (p = 0.03). Postoperatively, the time to first rescue analgesia was longer in group ESP than in group MTD (p = 0.03). The cumulative postoperative opioid consumption and pain scores were similar between groups.
CONCLUSIONS: The ESP block resulted in a reduced intraoperative opioid consumption compared with the control positive and negative groups.