Regional Anesthesia and Pain Medicine, Nov 16, 2020
To the Editor Having high respect to four eminent names and their life time experience, unfortuna... more To the Editor Having high respect to four eminent names and their life time experience, unfortunately we do not agree with their criticism on erector spinae plane block (ESPB).[1][1] We agree with Chin et al [2][2] that the physically detectable spread in cadaveric studies underestimate the true
Pediatric regional anesthesia is in the verge of a new era due to both widespread use of ultrasou... more Pediatric regional anesthesia is in the verge of a new era due to both widespread use of ultrasound and new defined fascial plane blocks. But we should still discuss the controversial issues like genetics and obesity, as there are some unclear issues according to limited data. In parallel with the changes in modern lifestyles, nutrition habits, and due to decreased physical activity obesity rates throughout the world continue to increase day by day. Change in both physiology and anatomy can lead to technical difficulties for performing regional techniques along with adjusting the drug doses. Although it might not be difficult to identify a landmark such as bone and vessels in obese pediatric patients, it would be challenging to visualize muscles and fascial planes. Even though local anesthetic toxicity rates are low in pediatric patients,1 it is difficult to detect while these patients are under general anesthesia (GA).2 Due to the possibility of a changed local anesthetic distribution clinicians should be aware of its manifestations under GA. When it comes to genetic disorders, it is even more difficult to talk clearly due to lack of data. There is only limited number of case reports and diversity of genetic disorders make it difficult to generalize recommendations. While the main concern must be the patient safety, consideration of regional technique should also be done according to risk versus benefit ratio, clinical experience and conditions of the practitioner. References Walker BJ, Long JB, Sathyamoorthy M, et al. Pediatric Regional Anesthesia Network Investigators. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology 2018;129:721–722. Lönnqvist, P-A, Ecoffey, C, Bosenberg, A, Suresh, S, Ivani, G. The European society of regional anesthesia and pain therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia I and II: what do they tell us?Curr Opin Anaesthesiol 2017;30:613–620.
Chronic pain is an important and specific healthcare problem, which affects at least 10% of the w... more Chronic pain is an important and specific healthcare problem, which affects at least 10% of the world’s population.1 In 1953 Bonica made the first and simplest definition of chronic pain as: ‘pain which persists past the normal time of healing stated’.2 He just did not made the definition but also stated its importance: ‘in its late phases, when it becomes intractable, it no longer serves a useful purpose and then becomes, through its mental and physical effects, a destructive force’. In parallel to this explanation, with our current knowledge, we now name chronic pain as a disease or syndrome as it is a multidimensional health problem.3 4 The standard treatment plan of chronic pain is a multidisciplinary approach, which includes pharmacology, physical therapies as well as psychological therapies and surgical interventions.5 However, this intensive treatment modality is inadequate for many patients and because chronic pain is sometimes resistant even to opioid drugs, ‘overuse’ or ‘abuse’ of prescription opioids has turned to an ‘opioid crisis’.6 This situation leads us to opioid sparing therapies where the inevitable role of neuromodulation starts. Definition of neuromodulation, in its simplest form, is; the process of inhibition, stimulation, modification or therapeutic alteration of the activities of central, peripheral and also autonomic nervous systems by using electricity.6 In fact neuromodulation therapy has been known since 15 AD by an accidental help of a torpedo fish.7 But the modern era of neuromodulation starts after the introduction of Melzack and Wall’s gate-control theory.8 They stated that there is ‘A gate control system modulates sensory input from the skin before it evokes pain perception and response’. the balance between the activation of small and large neural fibers determines if the gate is open or closed. Stimulation of large touch fibers (like in the situation we rub the painful area) would close the gate and lessen the pain. This description leaded clinicians to perform different modalities of neuromodulation at about the same time in late 60’s. Shealy et al.9 reported that the dorsal column stimulator was used to treat pain in the light of this theory and now this technique is called spinal cord stimulation [SCS]. Deep brain stimulation [DBS] was defined for the treatment of cancer pain10 and followed by the identification of peripheral nerve stimulation [PNS] for chronic pain.11 Deep Brain Stimulation (DBS) Surgically implanted units are used for DBS. Thin electrical leads placed deep in the brain, a small battery is generally placed under collarbone and an extension wire placed under the skin from skull passing down the neck to the battery unit. DBS targets specific sites in the brain with a low electrical mono- or bipolar stimulation: ventral posterolateral nucleus and ventral posteromedial nucleus (VPL/VPM) in the thalamus; periventricular grey matter and periaquaductal grey matter (PVG/PAG) and other regions surrounding the third ventricle and aqueduct of Sylvius, and the rostral anterior cingulate cortex (ACC) posterior to the anterior horns of the lateral ventricles.12 While the stimulation of VPL/VPM pleasant paraesthesia occurs and overcomes the painful sensation, stimulation of PVG/PAG induces a sense of warmth and analgesia. Stimulation of ACC with high frequency removes the affective aspect of pain.12 Spinal Cord Stimulation (SCS) SCS stimulation can be provided either via percutaneously placed epidural electrodes or via surgical paddle leads that implanted with a laminotomy.13 Electrodes can be placed between C5 to T11 according to the type and origin of the pain. There are three types of SCS as conventional/tonic SCS, High-frequency SCS and Burst SCS. In conventional SCS main goal is to mask the sensation of pain with paresthesia or tingling. Stimulations are low frequency (40–100 Hz), high amplitude (3.6–8.5 mA) and pulse widths ranging between 300–600 μs.6 Classic SCS treatment is effective for etiologies such as complex regional pain syndrome, failed back surgery syndrome, multiple sclerosis and diabetic neuropathy. This tonic, high charge stimulations are the cause of paresthesia feeling. Although its effect on pain relief, some patients reports that they are also uncomfortable with the sensation of paresthesia. Accordingly, in recent years, two new modalities with different stimulation waveforms and stimulation paradigms have been implemented to the clinical practice. High-frequency SCS involves a different high frequency (10 kHz) stimulation with amplitude ranging between 1–5 mA and with a pulse width at 30 μs. This frequency is at a sub-threshold level and therefore does not cause paresthesia. Although there are limited data about its efficacy and superiority to conventional SCS, it is shown that high-frequency SCS is a better option for chronic low back pain.6 Burst SCS is another novel mode of stimulation where burst frequency is 40 Hz and pulse frequency is…
In complex surgeries, such as myelomeningocele, the correct calculation of fluid and blood loss, ... more In complex surgeries, such as myelomeningocele, the correct calculation of fluid and blood loss, especially in newborns, is one of the biggest problems encountered by anesthetists. The Pleth Variable Index (PVI), is a parameter based on the changes in the perfusion index (PI) [1]. Although studies show that PVI is a valuable parameter to determine the volume status [2], there are not enough studies for use in infants during surgery and no definitive values have been identified. In these two cases, we aimed to discuss with the literature the method of anesthesia which we performed after obtaining written consent from patients' parents. Myelomeningocele was present in both patients. In addition to standard monitoring, the patients were monitored with Massimo Rainbow for PVI and PI. After general anesthesia was inducted with sevoflurane and 0,5 mg/kg IV remifentanyl, patients intubated with the right size uncuffed endotracheal tube. Anesthesia was maintained with 2%-2,5 sevoflurane in 40% oxygen/60% air. Case-1: 2500 g term male infant was taken to the operating room after 20 h following the birth. His hemoglobin was 18 g/dL; heart rate: 130, SpO2: 92 PI: 0,94, PVI: 23. Fluid therapy was started with 30 mL/h. After the first 20 min where the hemodynamic values were stable, PVI was increased to 31, a bolus dose of 25 cc fluid was given in 15 min and the fluid infusion was raised to 50 m/h and PVI values were between 21 and 27 during the operation. The operation was lasted in 1 h and completed uneventfully, total bleeding was calculated as 5 cc and blood transfusion was not performed. Case-2: 3000 g term male infant was taken to the operating room after 3 h following the birth. His hemoglobin was 19,5 g•dL −1 and SpO2: 98, heart rate: 124, blood pressure: 107/49, PI: 1,4, PVI: 28. Fluid therapy was started as 40 cc/h. After approximately 30 min later the operation was started, although PVI value was increased to 41, blood pressure was measured as 117/47 mmHg but fluid infusion was raised to 70 cc•h −1. When the blood pressure decreased to 90/38 mmHg (15 min
Ultrasound Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia f... more Ultrasound Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia for a 22 years old ASA II patient who has hemophilia A and undergoing circumcision surgery. 20 ml of 0.25% bupivacaine was used for DPNB. Surgery was completed under block without complication. 24 hours of analgesia was provided following surgery.
Regional Anesthesia and Pain Medicine, Feb 16, 2019
To the Editor, We have recently read the article of De Cassai et al [1][1] about the alternative ... more To the Editor, We have recently read the article of De Cassai et al [1][1] about the alternative ultrasound approach to the lumbar erector spinae plane block with great interest. However, we should point that we have already defined this approach and have described in the literature as ‘Aksu
Ainda precisamos de bloqueios centrais enquanto temos o bloqueio do eretor da espinha? Caso de cr... more Ainda precisamos de bloqueios centrais enquanto temos o bloqueio do eretor da espinha? Caso de criança de 2,5 meses de idade
Objective: Erector spinae plane block (ESP) is a novel technique for postoperative pain managemen... more Objective: Erector spinae plane block (ESP) is a novel technique for postoperative pain management. Primary aim of this study is to evaluate efficacy of ultrasound-guided ESP for providing postoperative analgesia in laparoscopic cholecystectomy (LC) procedures. Methods: Forty-six ASA I-II patients aged 20-70, who were scheduled to undergo elective LC were included in the study. Patients were randomized into two groups as ESP and Control group. Patients in the ESP group received ultrasound (US)-guided ESP block with 20 ml 0.25% bupivacaine. An intravenous patient-controlled analgesia device containing morphine was provided for all the patients in both groups. Morphine consumptions at postoperative 24 th hour and postoperative numeric rating scale (NRS) scores for pain were recorded. Results: Mean morphine consumptions at postoperative 24 th hour were 7.5 mg±5.8 in the ESP group while it was 13.2±5.6 mg in the control group (p<0.01). There was also a significant difference between the groups as for NRS scores at 12 th and 24 th hours (p=0.016, p=0.003 respectively). None of the patients in the ESP group complained about shoulder pain; but in the control group 9 patients reported shoulder pain. Conclusion: This study has shown that ESP block at T8 level has reduced the opioid consumption and showed a significant analgesic effect in patients undergoing LC.
The primary aim of this study was to evaluate the indications, effectiveness, application levels,... more The primary aim of this study was to evaluate the indications, effectiveness, application levels, and local anesthetic (LA) dosages used in erector spinae plane block (ESPB) in pediatric patients based on our clinical data. The secondary aim was to compare previously reported pediatric ESPBs with our data and to prepare a mini-guide for future clinical applications. Materials and methods One hundred and forty-one pediatric patients who received ESPB and were operated by the Department of Pediatric Surgery were included in this retrospective observational study. ESPB is routinely performed with 0.5 ml/kg 0.25% bupivacaine (max 20 ml). Demographic data and the type of surgery were recorded. Face, Legs, Activity, Cry, and Consolability (FLACC) or Numeric Rating Scale (NRS) scores, analgesic requirements, and the type of analgesic administered at postoperative period were recorded. Results ESPB was applied using three different techniques, the classic approach, the transverse approach, and the Aksu approach. Unilateral ESPB was performed on 112 patients, while 29 received a bilateral block. ESPB used for 13 different indications. Conclusion ESPB is a relatively safe and effective procedure for achieving opioid-free postoperative analgesia in many different surgical procedures in pediatric patients.
Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used ... more Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in "Pubmed" and "Google Scholar" database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.
The Turkish Journal of Anaesthesiology and Reanimation
Regional anaesthesia practice has changed dramatically, especially in the last 2-3 decades. Anaes... more Regional anaesthesia practice has changed dramatically, especially in the last 2-3 decades. Anaesthesiologists are far beyond doing only extremity and/or central neuraxial blocks. Unquestionably, the introduction of ultrasound into regional anaesthesia practice has a pivotal role in the so-called "renaissance" of regional anaesthesia today. Ultrasound allowed us to see not only the nerves themselves but also the fascial planes where nerves are located. In our own clinical practices, the diversity of the blocks is nothing comparable to what we used to do 15-20 years ago. Besides doing randomised controlled studies to test the newly introduced blocks, we often publish about selective blocks as case reports or short editorials just to inform the anaesthesia community, to let them know that all these different blocks are technically feasible and patients benefit a lot from receiving these selective blocks. Moreover, we need to recognise that with ultrasound guidance and improved understanding of sonoanatomy, new techniques to deliver local anaesthetics to target nerves will inevitably emerge ad hoc in expert hands with or without scientific publications. Today, we are discussing with Dr K.V. from Harvard University some essential issues about the future of regional anaesthesia, trying to answer the question whether there will be a block for every single patient entering the operating theatres to provide anaesthesia or analgesia or some benefits beyond anaesthesia. Do you think ESPB has changed the practice of regional anaesthesia and will it survive the test of time? Y.G. Erector Spina Plane Blocks (ESPB) is still a very young block introduced in 2016. There are thousands of publications trying ESPB almost for any indication in the operating room. Today, it is an integral part of our anaesthesia practice for breast surgery and included in the armamentarium of anaesthesiologists for thoracic surgery. It has always been challenging to perform regional anaesthesia for cardiac surgery due to anticoagulant use in the peri-operative period. Blocks like ESPB now offer an option for providing perioperative analgesia for cardiac surgery patients. For paediatric age group, ESPB has been shown to be very effective for both thoracic and abdominal surgeries. ESPB offered an option for spine surgery to reduce opioid requirement. I personally think ESPB is more effective in thoracic than lumbar levels and in the same manner in paediatrics compared to adults. This information comes from our extensive clinical experience with ESPB in different clinical scenarios. Generally speaking, ESPB has been a very successful adjunct to anaesthesia practice for many anaesthesiologists all over world due to technical simplicity and safety. K.V. OK-let's make this discussion more provocative… Yes, this may be a new block technique by designation and scientific interest, but to challenge the audience, it is not really a new block by injectate location/ distribution. In fact, the majority of paravertebral blocks (before or after ultrasound guidance) that fail to reach their intended target-the proper paravertebral space, deliver inadvertently the local anaesthetic mixture into planes, currently described and studied as retrolaminar plane, erector spinae plane, mid-point, even TLIP
Turkish Journal of Anaesthesiology and Reanimation
Cite this article as: Manici M, Salgın B, Gürkan Y. Anterior approach to suprascapular nerve bloc... more Cite this article as: Manici M, Salgın B, Gürkan Y. Anterior approach to suprascapular nerve block provides effective analgesia for shoulder pain following thoracic surgery. Turk J
Facioscapulohumeral dystrophy (FSHD) typically affects the periscapular muscles, resulting in sca... more Facioscapulohumeral dystrophy (FSHD) typically affects the periscapular muscles, resulting in scapular winging. Scapulothoracic arthrodesis (STA) stabilizes the scapula to provide better movement for these patients. Analgesia regimen for FSHD patients who received a single-shot erector spinae plane block (ESPB) and a catheter at the area were retrospectively analyzed in this study. Patients were asked to rate their pain postoperatively and only 5 of 10 patients needed rescue analgesic. No complications occurred. Our experience suggests that continuous ESPB may be helpful for providing analgesia in FSHD patients undergoing STA.
Regional Anesthesia and Pain Medicine, Nov 16, 2020
To the Editor Having high respect to four eminent names and their life time experience, unfortuna... more To the Editor Having high respect to four eminent names and their life time experience, unfortunately we do not agree with their criticism on erector spinae plane block (ESPB).[1][1] We agree with Chin et al [2][2] that the physically detectable spread in cadaveric studies underestimate the true
Pediatric regional anesthesia is in the verge of a new era due to both widespread use of ultrasou... more Pediatric regional anesthesia is in the verge of a new era due to both widespread use of ultrasound and new defined fascial plane blocks. But we should still discuss the controversial issues like genetics and obesity, as there are some unclear issues according to limited data. In parallel with the changes in modern lifestyles, nutrition habits, and due to decreased physical activity obesity rates throughout the world continue to increase day by day. Change in both physiology and anatomy can lead to technical difficulties for performing regional techniques along with adjusting the drug doses. Although it might not be difficult to identify a landmark such as bone and vessels in obese pediatric patients, it would be challenging to visualize muscles and fascial planes. Even though local anesthetic toxicity rates are low in pediatric patients,1 it is difficult to detect while these patients are under general anesthesia (GA).2 Due to the possibility of a changed local anesthetic distribution clinicians should be aware of its manifestations under GA. When it comes to genetic disorders, it is even more difficult to talk clearly due to lack of data. There is only limited number of case reports and diversity of genetic disorders make it difficult to generalize recommendations. While the main concern must be the patient safety, consideration of regional technique should also be done according to risk versus benefit ratio, clinical experience and conditions of the practitioner. References Walker BJ, Long JB, Sathyamoorthy M, et al. Pediatric Regional Anesthesia Network Investigators. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology 2018;129:721–722. Lönnqvist, P-A, Ecoffey, C, Bosenberg, A, Suresh, S, Ivani, G. The European society of regional anesthesia and pain therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia I and II: what do they tell us?Curr Opin Anaesthesiol 2017;30:613–620.
Chronic pain is an important and specific healthcare problem, which affects at least 10% of the w... more Chronic pain is an important and specific healthcare problem, which affects at least 10% of the world’s population.1 In 1953 Bonica made the first and simplest definition of chronic pain as: ‘pain which persists past the normal time of healing stated’.2 He just did not made the definition but also stated its importance: ‘in its late phases, when it becomes intractable, it no longer serves a useful purpose and then becomes, through its mental and physical effects, a destructive force’. In parallel to this explanation, with our current knowledge, we now name chronic pain as a disease or syndrome as it is a multidimensional health problem.3 4 The standard treatment plan of chronic pain is a multidisciplinary approach, which includes pharmacology, physical therapies as well as psychological therapies and surgical interventions.5 However, this intensive treatment modality is inadequate for many patients and because chronic pain is sometimes resistant even to opioid drugs, ‘overuse’ or ‘abuse’ of prescription opioids has turned to an ‘opioid crisis’.6 This situation leads us to opioid sparing therapies where the inevitable role of neuromodulation starts. Definition of neuromodulation, in its simplest form, is; the process of inhibition, stimulation, modification or therapeutic alteration of the activities of central, peripheral and also autonomic nervous systems by using electricity.6 In fact neuromodulation therapy has been known since 15 AD by an accidental help of a torpedo fish.7 But the modern era of neuromodulation starts after the introduction of Melzack and Wall’s gate-control theory.8 They stated that there is ‘A gate control system modulates sensory input from the skin before it evokes pain perception and response’. the balance between the activation of small and large neural fibers determines if the gate is open or closed. Stimulation of large touch fibers (like in the situation we rub the painful area) would close the gate and lessen the pain. This description leaded clinicians to perform different modalities of neuromodulation at about the same time in late 60’s. Shealy et al.9 reported that the dorsal column stimulator was used to treat pain in the light of this theory and now this technique is called spinal cord stimulation [SCS]. Deep brain stimulation [DBS] was defined for the treatment of cancer pain10 and followed by the identification of peripheral nerve stimulation [PNS] for chronic pain.11 Deep Brain Stimulation (DBS) Surgically implanted units are used for DBS. Thin electrical leads placed deep in the brain, a small battery is generally placed under collarbone and an extension wire placed under the skin from skull passing down the neck to the battery unit. DBS targets specific sites in the brain with a low electrical mono- or bipolar stimulation: ventral posterolateral nucleus and ventral posteromedial nucleus (VPL/VPM) in the thalamus; periventricular grey matter and periaquaductal grey matter (PVG/PAG) and other regions surrounding the third ventricle and aqueduct of Sylvius, and the rostral anterior cingulate cortex (ACC) posterior to the anterior horns of the lateral ventricles.12 While the stimulation of VPL/VPM pleasant paraesthesia occurs and overcomes the painful sensation, stimulation of PVG/PAG induces a sense of warmth and analgesia. Stimulation of ACC with high frequency removes the affective aspect of pain.12 Spinal Cord Stimulation (SCS) SCS stimulation can be provided either via percutaneously placed epidural electrodes or via surgical paddle leads that implanted with a laminotomy.13 Electrodes can be placed between C5 to T11 according to the type and origin of the pain. There are three types of SCS as conventional/tonic SCS, High-frequency SCS and Burst SCS. In conventional SCS main goal is to mask the sensation of pain with paresthesia or tingling. Stimulations are low frequency (40–100 Hz), high amplitude (3.6–8.5 mA) and pulse widths ranging between 300–600 μs.6 Classic SCS treatment is effective for etiologies such as complex regional pain syndrome, failed back surgery syndrome, multiple sclerosis and diabetic neuropathy. This tonic, high charge stimulations are the cause of paresthesia feeling. Although its effect on pain relief, some patients reports that they are also uncomfortable with the sensation of paresthesia. Accordingly, in recent years, two new modalities with different stimulation waveforms and stimulation paradigms have been implemented to the clinical practice. High-frequency SCS involves a different high frequency (10 kHz) stimulation with amplitude ranging between 1–5 mA and with a pulse width at 30 μs. This frequency is at a sub-threshold level and therefore does not cause paresthesia. Although there are limited data about its efficacy and superiority to conventional SCS, it is shown that high-frequency SCS is a better option for chronic low back pain.6 Burst SCS is another novel mode of stimulation where burst frequency is 40 Hz and pulse frequency is…
In complex surgeries, such as myelomeningocele, the correct calculation of fluid and blood loss, ... more In complex surgeries, such as myelomeningocele, the correct calculation of fluid and blood loss, especially in newborns, is one of the biggest problems encountered by anesthetists. The Pleth Variable Index (PVI), is a parameter based on the changes in the perfusion index (PI) [1]. Although studies show that PVI is a valuable parameter to determine the volume status [2], there are not enough studies for use in infants during surgery and no definitive values have been identified. In these two cases, we aimed to discuss with the literature the method of anesthesia which we performed after obtaining written consent from patients' parents. Myelomeningocele was present in both patients. In addition to standard monitoring, the patients were monitored with Massimo Rainbow for PVI and PI. After general anesthesia was inducted with sevoflurane and 0,5 mg/kg IV remifentanyl, patients intubated with the right size uncuffed endotracheal tube. Anesthesia was maintained with 2%-2,5 sevoflurane in 40% oxygen/60% air. Case-1: 2500 g term male infant was taken to the operating room after 20 h following the birth. His hemoglobin was 18 g/dL; heart rate: 130, SpO2: 92 PI: 0,94, PVI: 23. Fluid therapy was started with 30 mL/h. After the first 20 min where the hemodynamic values were stable, PVI was increased to 31, a bolus dose of 25 cc fluid was given in 15 min and the fluid infusion was raised to 50 m/h and PVI values were between 21 and 27 during the operation. The operation was lasted in 1 h and completed uneventfully, total bleeding was calculated as 5 cc and blood transfusion was not performed. Case-2: 3000 g term male infant was taken to the operating room after 3 h following the birth. His hemoglobin was 19,5 g•dL −1 and SpO2: 98, heart rate: 124, blood pressure: 107/49, PI: 1,4, PVI: 28. Fluid therapy was started as 40 cc/h. After approximately 30 min later the operation was started, although PVI value was increased to 41, blood pressure was measured as 117/47 mmHg but fluid infusion was raised to 70 cc•h −1. When the blood pressure decreased to 90/38 mmHg (15 min
Ultrasound Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia f... more Ultrasound Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia for a 22 years old ASA II patient who has hemophilia A and undergoing circumcision surgery. 20 ml of 0.25% bupivacaine was used for DPNB. Surgery was completed under block without complication. 24 hours of analgesia was provided following surgery.
Regional Anesthesia and Pain Medicine, Feb 16, 2019
To the Editor, We have recently read the article of De Cassai et al [1][1] about the alternative ... more To the Editor, We have recently read the article of De Cassai et al [1][1] about the alternative ultrasound approach to the lumbar erector spinae plane block with great interest. However, we should point that we have already defined this approach and have described in the literature as ‘Aksu
Ainda precisamos de bloqueios centrais enquanto temos o bloqueio do eretor da espinha? Caso de cr... more Ainda precisamos de bloqueios centrais enquanto temos o bloqueio do eretor da espinha? Caso de criança de 2,5 meses de idade
Objective: Erector spinae plane block (ESP) is a novel technique for postoperative pain managemen... more Objective: Erector spinae plane block (ESP) is a novel technique for postoperative pain management. Primary aim of this study is to evaluate efficacy of ultrasound-guided ESP for providing postoperative analgesia in laparoscopic cholecystectomy (LC) procedures. Methods: Forty-six ASA I-II patients aged 20-70, who were scheduled to undergo elective LC were included in the study. Patients were randomized into two groups as ESP and Control group. Patients in the ESP group received ultrasound (US)-guided ESP block with 20 ml 0.25% bupivacaine. An intravenous patient-controlled analgesia device containing morphine was provided for all the patients in both groups. Morphine consumptions at postoperative 24 th hour and postoperative numeric rating scale (NRS) scores for pain were recorded. Results: Mean morphine consumptions at postoperative 24 th hour were 7.5 mg±5.8 in the ESP group while it was 13.2±5.6 mg in the control group (p<0.01). There was also a significant difference between the groups as for NRS scores at 12 th and 24 th hours (p=0.016, p=0.003 respectively). None of the patients in the ESP group complained about shoulder pain; but in the control group 9 patients reported shoulder pain. Conclusion: This study has shown that ESP block at T8 level has reduced the opioid consumption and showed a significant analgesic effect in patients undergoing LC.
The primary aim of this study was to evaluate the indications, effectiveness, application levels,... more The primary aim of this study was to evaluate the indications, effectiveness, application levels, and local anesthetic (LA) dosages used in erector spinae plane block (ESPB) in pediatric patients based on our clinical data. The secondary aim was to compare previously reported pediatric ESPBs with our data and to prepare a mini-guide for future clinical applications. Materials and methods One hundred and forty-one pediatric patients who received ESPB and were operated by the Department of Pediatric Surgery were included in this retrospective observational study. ESPB is routinely performed with 0.5 ml/kg 0.25% bupivacaine (max 20 ml). Demographic data and the type of surgery were recorded. Face, Legs, Activity, Cry, and Consolability (FLACC) or Numeric Rating Scale (NRS) scores, analgesic requirements, and the type of analgesic administered at postoperative period were recorded. Results ESPB was applied using three different techniques, the classic approach, the transverse approach, and the Aksu approach. Unilateral ESPB was performed on 112 patients, while 29 received a bilateral block. ESPB used for 13 different indications. Conclusion ESPB is a relatively safe and effective procedure for achieving opioid-free postoperative analgesia in many different surgical procedures in pediatric patients.
Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used ... more Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in "Pubmed" and "Google Scholar" database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.
The Turkish Journal of Anaesthesiology and Reanimation
Regional anaesthesia practice has changed dramatically, especially in the last 2-3 decades. Anaes... more Regional anaesthesia practice has changed dramatically, especially in the last 2-3 decades. Anaesthesiologists are far beyond doing only extremity and/or central neuraxial blocks. Unquestionably, the introduction of ultrasound into regional anaesthesia practice has a pivotal role in the so-called "renaissance" of regional anaesthesia today. Ultrasound allowed us to see not only the nerves themselves but also the fascial planes where nerves are located. In our own clinical practices, the diversity of the blocks is nothing comparable to what we used to do 15-20 years ago. Besides doing randomised controlled studies to test the newly introduced blocks, we often publish about selective blocks as case reports or short editorials just to inform the anaesthesia community, to let them know that all these different blocks are technically feasible and patients benefit a lot from receiving these selective blocks. Moreover, we need to recognise that with ultrasound guidance and improved understanding of sonoanatomy, new techniques to deliver local anaesthetics to target nerves will inevitably emerge ad hoc in expert hands with or without scientific publications. Today, we are discussing with Dr K.V. from Harvard University some essential issues about the future of regional anaesthesia, trying to answer the question whether there will be a block for every single patient entering the operating theatres to provide anaesthesia or analgesia or some benefits beyond anaesthesia. Do you think ESPB has changed the practice of regional anaesthesia and will it survive the test of time? Y.G. Erector Spina Plane Blocks (ESPB) is still a very young block introduced in 2016. There are thousands of publications trying ESPB almost for any indication in the operating room. Today, it is an integral part of our anaesthesia practice for breast surgery and included in the armamentarium of anaesthesiologists for thoracic surgery. It has always been challenging to perform regional anaesthesia for cardiac surgery due to anticoagulant use in the peri-operative period. Blocks like ESPB now offer an option for providing perioperative analgesia for cardiac surgery patients. For paediatric age group, ESPB has been shown to be very effective for both thoracic and abdominal surgeries. ESPB offered an option for spine surgery to reduce opioid requirement. I personally think ESPB is more effective in thoracic than lumbar levels and in the same manner in paediatrics compared to adults. This information comes from our extensive clinical experience with ESPB in different clinical scenarios. Generally speaking, ESPB has been a very successful adjunct to anaesthesia practice for many anaesthesiologists all over world due to technical simplicity and safety. K.V. OK-let's make this discussion more provocative… Yes, this may be a new block technique by designation and scientific interest, but to challenge the audience, it is not really a new block by injectate location/ distribution. In fact, the majority of paravertebral blocks (before or after ultrasound guidance) that fail to reach their intended target-the proper paravertebral space, deliver inadvertently the local anaesthetic mixture into planes, currently described and studied as retrolaminar plane, erector spinae plane, mid-point, even TLIP
Turkish Journal of Anaesthesiology and Reanimation
Cite this article as: Manici M, Salgın B, Gürkan Y. Anterior approach to suprascapular nerve bloc... more Cite this article as: Manici M, Salgın B, Gürkan Y. Anterior approach to suprascapular nerve block provides effective analgesia for shoulder pain following thoracic surgery. Turk J
Facioscapulohumeral dystrophy (FSHD) typically affects the periscapular muscles, resulting in sca... more Facioscapulohumeral dystrophy (FSHD) typically affects the periscapular muscles, resulting in scapular winging. Scapulothoracic arthrodesis (STA) stabilizes the scapula to provide better movement for these patients. Analgesia regimen for FSHD patients who received a single-shot erector spinae plane block (ESPB) and a catheter at the area were retrospectively analyzed in this study. Patients were asked to rate their pain postoperatively and only 5 of 10 patients needed rescue analgesic. No complications occurred. Our experience suggests that continuous ESPB may be helpful for providing analgesia in FSHD patients undergoing STA.
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