IntroductionRecently, concerns have been raised regarding the impact of anesthetic choice on outcomes for patients undergoing hypospadias repair. It has been suggested that caudal epidural anesthesia (CEA) may be associated with increased postoperative complications, such as urethrocutaneous fistula and glanular dehiscence. However, subsequent studies have found no association between CEA and increased complications. Spinal anesthesia (SA) is another technique that can provide surgical blockade during hypospadias repair. However, no studies have examined outcomes for pediatric patients undergoing hypospadias repair under awake SA.MethodsWe performed a single-center retrospective review on all patients who underwent single-stage primary hypospadias repair from 2016 until 2023. Data collected included patient demographics, anesthetic details, severity of hypospadias, duration of procedure, and postoperative complications.Results805 patients underwent single-stage hypospadias repair during the study period. 117 (14.5%) had GA alone, 563 (70%) had GA with CEA, and 125 (15.5%) had SA. Duration of surgery was significantly longer for patients in the GA and CEA groups compared to the SA group, and more patients in the GA and CEA groups had a higher severity of hypospadias. We did not find significant differences in the odds ratio for postoperative complications between groups.DiscussionIn our retrospective analysis, we did not find a difference between anesthetic groups in the rate of postoperative complications. Patients who had SA were younger and had a shorter median surgical time. Because SA has a limited duration, patients with more complicated pathologies may not be offered SA as an option. SA is an underutilized technique for pediatric urologic procedures, but has several benefits over GA for infants and young children.ConclusionSA can be successfully utilized for hypospadias surgery in pediatric patients without an increase in postoperative complications. Future studies on this topic are warranted due to significant baseline differences between patient groups.

While propofol is a commonly utilized medication for sedation during gastrointestinal endoscopy, it is associated with adverse effects such as hypotension and injection pain. This trial was conducted to test the hypothesis that chloroprocaine can reduce the requirement for propofol and alleviate injection pain during gastrointestinal endoscopy. Sixty patients undergoing gastrointestinal endoscopy were enrolled and randomly divided into study group (Group CP) and control group (Group C). Patients in Group CP received intravenous chloroprocaine 2 mg/kg, followed by continuous infusion at 6 mg·kg-1·h-1 until the end of examination. Patients in Group C received the same volume of saline. Subsequently, all patients were intravenously administered sufentanil at a dose of 0.05μg/kg. Thirty seconds later, propofol was uniformly infused intravenously at a rate of 60 mL/min using an infusion pump. The primary outcome was the consumption of propofol. Secondary outcomes included the incidence of hypoxemia, hypotension, bradycardia, injection pain, and coughing/body movement during examination. The recovery time, PACU stay time, postoperative pain score, and endoscopists' satisfaction score were also recorded. Group CP demonstrated a significantly lower total requirement for propofol compared to Group C, with means of (119±14) mg and (148±18) mg respectively, P<0.001. This trend was also observed for both the first and supplemental doses. There were no significant differences between the two groups regarding intraoperative adverse events. The incidence of injection pain in Group CP was lower than that in Group C (P=0.007). The recovery time [(4.7±1.4) vs (6.6±1.3), P<0.001], PACU stay time [(13.0±2.9) vs (16.7±3.0), P<0.001] and postoperative pain score [(1.9±0.7) vs (2.5±0.7), P=0.002] in Group CP were lower than those in Group C. Intravenous chloroprocaine reduces the requirement for propofol, alleviates propofol injection pain, and improves recovery in patients undergoing gastrointestinal endoscopy.

This prospective study aimed to compare the analgesic efficacy and adverse effects of intrathecal morphine, dexmedetomidine, and a combination of both in patients undergoing total knee replacement (TKR). This randomized prospective study was carried out in Tanta university hospital in orthopedic surgery for 6 months on 105 adult patients with American Society of Anesthesiologists Physical Status Class II and III, aged > 50 years, and scheduled for total knee replacement surgery randomly allocated into morphine group received 0.5% heavy bupivacaine plus 0.1 mg of morphine, morphine/ dexmedetomidine group, received 0.5% heavy bupivacaine plus 0.1 mg of morphine and 5 mcg of dexmedetomidine and dexmedetomidine group received 0.5% heavy bupivacaine plus 5 mcg of dexmedetomidine. The time of the first required analgesia, postoperative pain severity, the total dose of morphine, postoperative complication, and the patient's level of sedation were recorded. About half of the patients in the dexmedetomidine group requested first rescue analgesia 6 hours after the operation, significantly shorter than the other two groups. On the other hand, the other two groups show no significant difference between them regarding the first required analgesia. At rest, the dexmedetomidine group have significantly higher VAS with a significant increase in patients who required morphine as rescue analgesia than the other two groups. While at movement, patients in the dexmedetomidine group felt pain at 4 hrs postoperatively with significantly higher VAS than the other two groups. At the same time, the sedation score was significantly lower in the dexmedetomidine group than in the other two groups. 22.2% of cases in the morphine group developed nausea and vomiting with a significant difference between the three groups. Despite the absence of substantial side effects, our findings did not suggest enhanced analgesia with the combination of intrathecal morphine and dexmedetomidine.

Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA. This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission. The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain. The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study's population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy. This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.

Several studies have applied lumbar spinal anesthesia (SA) with isobaric/hyperbaric bupivacaine and opioids in elective laparoscopic cholecystectomy (LC), documenting a superiority of the methodic over general anesthesia (GA) in terms of perioperative pain, nausea, and vomiting, though with a notable incidence of intraoperative right shoulder pain, potentially responsible for conversion to GA. This case series presents an opioid-free scheme of segmental thoracic spinal anesthesia (STSA) with hypobaric ropivacaine, reporting its benefits mainly in terms of shoulder pain occurrence. Hypobaric STSA was performed in nine patients undergoing elective LC between May 1 and September 1, 2022. The level of the needle insertion was included between T8 and T9, via a median or a paramedian approach. Midazolam (0.03 mg/kg) and Ketamine (0.3 mg/kg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 5 mg and then isobaric ropivacaine at a dose of 10 mg. Patients were placed in anti-Trendelenburg position for the entire duration of surgery. LC was conducted through the standard 3 or 4 ports technique with pneumoperitoneum maintained at a pressure of 8-10 mmHg. Mean patient age was 75.7 (±17.5) years, with a mean ASA score and Charlson comorbidity index (CCI) of 2.7 (±0.7) and 4.9 (±2.7), respectively. STSA was completed without complications in all patients, with no need for conversion to GA. Mean operative time and SA duration were 37.5 (±8.7) and 145.2 (±21.8) min, respectively. Intraoperatively, no shoulder or abdominal pain and nausea were reported, with only four and two patients requiring vasopressor and sedative intravenous drugs, respectively. Postoperatively, overall mean VAS pain score and within the first 12 hafter surgery were 3 (±2) and 4 (±2), respectively. Median length of stay was 2 (range = 1-3) days. Hypobaric opioid-free STSA appears to be a promising approach for laparoscopic surgeries, with minimal to null occurrence of shoulder pain. Larger prospective studies are required to validate these findings.

PurposeFew studies have described segmental thoracic spinal anesthesia (STSA) as primary anesthesiologic method in breast and axillary surgery, documenting the association of intrathecal local anesthetics and opioids. This case series reports an opioid-free scheme of STSA in four elderly patients undergoing major breast and axillary oncological surgery.Patients and MethodsSTSA was performed in three female patients undergoing unilateral mastectomy ± axillary lymph node dissection (ALND) or sentinel lymph node biopsy for invasive ductal carcinoma and in one male patient undergoing ALND for melanoma metastases. The level of needle insertion was included between T6-8, via a median or paramedian approach. Midazolam (2 mg) and ketamine (20 mg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 8 mg. The level of sensory blockade achieved was comprised between C2-3 and T11-12. Postoperative analgesia was maintained through continuous intravenous administration of Ketorolac by an elastomeric pump (90 mg over 24 hrs.).ResultsSpinal anesthesia was completed without complications in all patients. Conversion to general anesthesia (GA) and perioperative intravenous sedation were not required. No major postoperative complications and no episodes of postoperative nausea and vomiting (PONV) were reported. No rescue analgesic was administered. All patients were discharged in postoperative day 2 and are alive at 30, 29, 27 and 13 months after surgery, respectively. High grade of satisfaction on the anesthesiologic method was expressed by all cases.ConclusionSTSA with local anesthetic plus midazolam and ketamine might be considered a safe and effective alternative to GA, even in surgeries involving the breast and axillary region, particularly in elderly and frail patients. Larger prospective studies are required to validate these findings.

Introduction and ObjectivesLocal anesthesia is essential in dentistry in providing intraoperative analgesia and anesthesia. However, knowledge related to its use for management of post-operative pain is limited. Perioperative pain management is especially important for root canal treatment (ie, endodontic therapy), performed by endodontists. In this study, we sought to better understand endodontists’ attitudes regarding the use of long-lasting anesthetic, namely 0.5% bupivacaine HCl with 1:200,000 epinephrine, for the management of post-endodontic pain. Additionally, we aimed to understand the perspectives of dental patients about receiving longer lasting anesthesia for endodontic therapy and to determine factors that affect their anesthetic preferences within the orofacial region.MethodsAn email invitation to participate in an anonymous online survey was sent to members of the American Association of Endodontists. Also, 82 patients attending an in-person visit to an endodontic clinic were recruited to the study.ResultsData from 474 endodontic practitioners and 82 patients included in analysis. Among practitioners, the majority reported to either never (33.31%) or rarely (34.84%) using bupivacaine. Most chose “I don’t think I need it” (47%) and “patient discomfort because of longer duration of soft tissue anesthesia” (30.81%) as reasons for not preferring the use of bupivacaine. Of the practitioners who reported at least rare use, most chose bupivacaine for post-operative pain management (78.02%). Conversely, 52% of patients reported that they were likely/most likely to request long-lasting anesthetics for post-operative pain control.ConclusionBupivacaine is rarely used as a post-operative pain management strategy for endodontic therapy. Specifically, bupivacaine is not preferred not because of adverse events, toxicity, or slow onset concerns, but rather, because of longer duration of soft tissue anesthesia. However, our data suggest that patients may be willing to receive long-lasting anesthesia. Further patient-centered research should investigate the use of long-lasting anesthetic agents for management of post-endodontic pain.

BackgroundInterscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery.MethodsWe performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique.ResultsAfter statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters.ConclusionInterscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.

PurposeSensory innervation in the carotid triangle involves the cervical plexus, cranial nerves, and the sympathetic trunk. This innervation also applies to skin incision, including various anatomical structures with potentially different innervation, such as the skin (dermatomes), the platysma (myotomes), and the superficial layer of the cervical fascia (fasciotomes), as well as retromandibular retractor insertion (co-innervation: V, VII). The aim of this anatomical study was to develop an injection technique for carotid endarterectomies to additionally block anastomoses between the transverse cervical nerve (TCN), the cervical branch VII (CB VII), and the marginal mandibular branch VII (MMB VII). These anastomoses are also termed superficial cervical ansa (SCA).Materials and MethodsPreparations (n=16) were performed on unembalmed donor cadavers (n=8). Subplatysmal injections (each using 5 mL of Alcian blue) were performed cranially within the carotid triangle between the anterior margin of the sternocleidomastoid muscle and the submandibular gland.ResultsAnastomoses between the TCN, CB VII, and MMB VII were stained in all preparations (n=16).ConclusionThis anatomical study presents an ultrasound-guided subplatysmal SCA block to optimize, in addition to a cervical plexus block, the quality of anesthesia for carotid endarterectomies.

Percutaneous radiofrequency ablation (PRFA) of solid tumors is a minimally invasive procedure used to treat primary or metastatic cancer lesions via needle targeted thermal energy transfer. Some of the most common tumor lesions treated using PRFA include those within the liver, lungs and kidneys. Additionally, bone, thyroid, and breast lesions can also be treated. In most cases, this procedure is performed outside of the operating room in a specialized radiology suite. As a result, the clinician must adapt in many cases to the specific environmental issues attendant to providing anesthesia outside the operating room, including the lack of availability of an anesthesia machine in some cases, and frequently a lack of adequate scavenging and other specialized monitoring and equipment. At this time, routine practice and anesthetic prescriptions for PRFA can vary widely, ranging from patients receiving local anesthesia alone, to monitored anesthesia care, to regional anesthesia, to combined regional and general anesthesia. The choice of anesthetic technique will depend on tumor location and practitioner experience. This review aims to summarize the current state of the art in terms of anesthetic techniques for patients undergoing PRFA of solid tumors.