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      Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial

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          Abstract

          Background

          Breast cancer surgery is one of the most common surgeries among the female population. Nearly half of the patients suffer chronic pain following breast cancer surgery, and 24% of them categorizing their pain as moderate to high. In this study, effects of ultrasound-guided erector spinae plane (ESP) block performed using two different concentrations of bupivacaine on postoperative tramadol consumption, pain scores, and intraoperative fentanyl requirements among patients who underwent radical mastectomy surgery were compared.

          Methods

          This double-blinded, prospective, and randomized study included patients with age ranged 18–70, American Society of Anesthesiologist physical status I–II, and scheduled for unilateral modified radical mastectomy surgery. The patients were randomly allocated into two groups. In group I, ESP block was performed with 0.375% bupivacaine. In group II, ESP block was performed with 0.25% bupivacaine. General anesthesia was induced in both groups according to the standard procedures. When the pain score was ≥4, patients received intravenous (i.v.) 25 mcg fentanyl in the recovery room or 4 mg of morphine in the surgical ward as a rescue analgesia. The main measurements were postoperative tramadol consumption; Numerical Rating Scale (NRS) scores 15, 30, and 60 min and 12 and 24 h postoperatively; and intraoperative fentanyl requirements.

          Results

          In total, 42 patients (21 patients in each group) were included in the study. The mean tramadol consumption at the postoperative 24th h was 149.52 ± 25.39 mg in group I, and 199.52 ± 32.78 mg in group II ( p = 0.001). In group I, the NRS scores were significantly lower at every time points compared with those in group II. The mean intraoperative fentanyl requirement was similar in the two groups.

          Conclusion

          Although ESP block performed with both concentrations of bupivacaine provided effective postoperative analgesia, the higher concentration of bupivacaine significantly reduced postoperative tramadol consumption after radical mastectomy surgery.

          Clinical trial registration

          The study was registered prospectively with the Australian New Zealand Clinical Trials Registry (trial ID: ACTRN12618001334291at 08/08/2018).

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          A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers.

          Recently, two centers have independently developed a risk score for predicting postoperative nausea and vomiting (PONV). This study investigated (1) whether risk scores are valid across centers and (2) whether risk scores based on logistic regression coefficients can be simplified without loss of discriminating power. Adult patients from two centers (Oulu, Finland: n = 520, and Wuerzburg, Germany: n = 2202) received inhalational anesthesia (without antiemetic prophylaxis) for various types of surgery. PONV was defined as nausea or vomiting within 24 h of surgery. Risk scores to estimate the probability of PONV were obtained by fitting logistic regression models. Simplified risk scores were constructed based on the number of risk factors that were found significant in the logistic regression analyses. Original and simplified scores were cross-validated. A combined data set was created to estimate a potential center effect and to construct a final risk score. The discriminating power of each score was assessed using the area under the receiver operating characteristic curves. Risk scores derived from one center were able to predict PONV from the other center (area under the curve = 0.65-0.75). Simplification did not essentially weaken the discriminating power (area under the curve = 0.63-0.73). No center effect could be detected in a combined data set (odds ratio = 1.06, 95% confidence interval = 0.71-1.59). The final score consisted of four predictors: female gender, history of motion sickness (MS) or PONV, nonsmoking, and the use of postoperative opioids. If none, one, two, three, or four of these risk factors were present, the incidences of PONV were 10%, 21%, 39%, 61% and 79%. The risk scores derived from one center proved valid in the other and could be simplified without significant loss of discriminating power. Therefore, it appears that this risk score has broad applicability in predicting PONV in adult patients undergoing inhalational anesthesia for various types of surgery. For patients with at least two out of these four identified predictors a prophylactic antiemetic strategy should be considered.
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            The Erector Spinae Plane Block Provides Visceral Abdominal Analgesia in Bariatric Surgery

            Postoperative pain after bariatric surgery can be significant and yet difficult to manage. These patients frequently have associated obstructive sleep apnea and are at risk of respiratory depression with opioid analgesia. Abdominal wall blocks such as the subcostal transversus abdominis plane block are not of significant benefit, probably in part because they provide only somatic analgesia. The ultrasound-guided erector spinae plane (ESP) block is a recently described regional anesthetic technique for providing thoracic analgesia when performed at the level of the T5 transverse process. Local anesthetic injected into the fascial plane deep to the erector spinae muscle spreads in a craniocaudal fashion over several levels. Local anesthetic also penetrates anteriorly through the intertransverse connective tissue and enters the thoracic paravertebral space where it can potentially block not only the ventral and dorsal rami of spinal nerves but also the rami communicantes that transmit sympathetic fibers. Coupled with the fact that the erector spinae muscle and ESP extend down to the lumbar spine, this suggests that the ESP block could result in both visceral and somatic abdominal analgesia if the injection were performed at a lower thoracic level. We describe a series of 3 cases that illustrate the efficacy of bilateral ESP blocks performed at the level of the T7 transverse process for relieving visceral abdominal pain following bariatric surgery. Further investigation is recommended to establish the potential of the ESP block as an analgesic modality in abdominal surgery.
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              Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: a population-based cohort study.

              Chronic postsurgical pain (CPSP) is a common postoperative adverse event affecting up to half of women undergoing breast cancer surgery, yet few epidemiological studies have prospectively investigated the role of preoperative, intraoperative, and postoperative risk factors for pain onset and chronicity. We prospectively investigated preoperative sociodemographic and psychological factors, intraoperative clinical factors, and acute postoperative pain in a prospective cohort of 362 women undergoing surgery for primary breast cancer. Intraoperative nerve handling (division or preservation) of the intercostobrachial nerve was recorded. At 4 and 9months after surgery, incidence of chronic painful symptoms not present preoperatively was 68% and 63%, respectively. Univariate analysis revealed that multiple psychological factors and nerve division was associated with chronic pain at 4 and 9months. In a multivariate model, independent predictors of CPSP at 4months included younger age and acute postoperative pain (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.12 to 1.60), whereas preoperative psychological robustness (OR 0.70, 95% CI 0.49 to 0.99), a composite variable comprising high dispositional optimism, high positive affect, and low emotional distress, was protective. At 9months, younger age, axillary node clearance (OR 2.97, 95% CI 1.09 to 8.06), and severity of acute postoperative pain (OR 1.17, 95% CI 1.00 to 1.37) were predictive of pain persistence. Of those with CPSP, 25% experienced moderate to severe pain and 40% were positive on Douleur Neuropathique 4 and Self-Complete Leeds Assessment of Neuropathic Symptoms and Signs pain scales. Overall, a high proportion of women report painful symptoms, altered sensations, and numbness in the upper body within the first 9months after resectional breast surgery and cancer treatment.
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                Author and article information

                Contributors
                basak_ugurlu@yahoo.com
                meltoker@gmail.com
                alihsanuysal@gmail.com
                sedemirbilek@gmail.com
                Journal
                BMC Anesthesiol
                BMC Anesthesiol
                BMC Anesthesiology
                BioMed Central (London )
                1471-2253
                4 March 2019
                4 March 2019
                2019
                : 19
                : 31
                Affiliations
                [1 ]ISNI 0000 0001 0703 3794, GRID grid.411861.b, Department of Anesthesiology and Reanimation, , Muğla Sıtkı Koçman University, ; Menteşe Muğla, Turkey
                [2 ]ISNI 0000 0001 0703 3794, GRID grid.411861.b, Department of Anesthesiology and Reanimation, , Muğla Sıtkı Koçman University Training and Research Hospital, ; Menteşe Muğla, Turkey
                Author information
                http://orcid.org/0000-0002-8165-3438
                Article
                700
                10.1186/s12871-019-0700-3
                6399855
                30832580
                f3d48aab-0798-4224-a3d0-c71b7417ac02
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 9 October 2018
                : 20 February 2019
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Anesthesiology & Pain management
                analgesia,erector spinae plane block,mastectomy,postoperative pain,ultrasound

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