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Vol 14, No 3 (2020)

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Propofol and postoperative pain. Time to change priorities?

Ovechkin A.M.


Currently, the use of inhalational anesthetics is the basic method of general anesthesia. Propofol-based total intravenous anesthesia (TIVA) is not widely used. However, over the past years, evidence-based medicine data have been obtained on a decrease in the intensity of postoperative pain and the need for analgesics in patients operated on under the conditions of propofol-based TIVA, compared with inhalation anesthesia. It is possible that this fact will form the basis for revising general anesthesia regimens.

Regional Anesthesia and Acute Pain Management. 2020;14(3):118-120
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Animal models of chronic pain. In vivo experiments

Khinovker V.V., Khinovker E.V.


As a result of population aging and increasing of comorbide patients procent, chronic pain nowadays is the one of the most important medical problems and its treatment becoming one of progressive and popular researching topics. First part of acute or chronic pain research is a model that meets the specified criteria. First model of cronic pain – sciatic nerve damaging was founded and proven more than 30 years ago. Nowadays there is a lot of in vivo and in vitro models that matched with different pathologies and also mechanisms of chronic nociceptive and neuropathic pain on different levels have been learned. In this article we review the most effective and often used rat models of chronic pain its mechanisms and assessment methods. The information based on the most citated articles for 10 years.

Regional Anesthesia and Acute Pain Management. 2020;14(3):121-129
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Obturator nerve block

Koriachkin V.A., Zabolotskii D.V., Gribanov D.V., Antoshkova T.A.


One of the “forgotten” techniques of regional anesthesia is blockade of the obturator nerve, which was performed using anatomical landmarks and neurostimulation. In recent years, ultrasonic navigation methods have gained wide popularity when using regional blockades. The purpose of the review is to present the current understanding of the use of obturator nerve block in clinical practice. The review presents the anatomical features of the obturator nerve passage, surgical and therapeutic indications for the use of its blockade. The technique for performing obturator blockade using ultrasound navigation is described in detail. Blockade of the obturator nerve using ultrasound navigation can reduce the likelihood of surgical complications during transurethral resection of a tumor located on the lateral wall of the bladder, improve analgesia after hip and knee surgery, and effectively relieve spastic conditions of the adductor muscles of the hip.

Regional Anesthesia and Acute Pain Management. 2020;14(3):130-140
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Original study articles

The choice of the method of anesthetic management of gynecological operations in patients with different sensitivity of peripheral chemoreflex

Golovataya M.V., Trembach N.V., Soghomonyan K.A., Dmitriev A.A.


Objective — comparative assessment of spinal and epidural anesthesia during gynecological operations in patients with different sensitivity of peripheral chemoreflex.

Material and Methods. Prospective observational blind study, 152 gynecological patients, elective surgery. The day before the surgery, the sensitivity of peripheral chemoreflex was determined by the duration of an arbitrary threshold apnea in a test with a delayed respiration. According to the duration of the test, the patients were divided into groups: high risk of developing complications (group “1”) and low risk of developing complications (group “2”). Each group contains subgroups depending on the type of anesthesia: spinal or epidural. During the operation and in the early postoperative period, critical incidents were recorded.

Results and Conclusion(s). During anesthesia in gynecological patients from intraoperative critical incidents is revealed hypotension. The use of epidural anesthesia in patients with a high risk of developing complications can reduce the incidence of hypotension and postoperative complications. In patients with a low risk of developing complications, both epidural and spinal anesthesia can be used.

Regional Anesthesia and Acute Pain Management. 2020;14(3):141-148
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Excretion of ropivacaine with breast milk during prolonged analgesia of a postoperative wound

Vinokurova А.А., Hofenberg M.A., Bagin V.A., Dubrovin S.G., Rudnov V.A.


The aim of our study was to evaluate the safety of ropivacaine given to lactating patients as a continuous infusion according to the selected local continuous wound infiltration (CWI) protocol after cesarean section (CS).

Materials and methods. Elective CSs were performed under spinal anesthesia with bupivacaine 5% -2 ml at the L2–L3 level. At the end of the operation, a 22 cm multiperforated catheter was placed in the surgical wound under the aponeurosis. 3 hours after spinal anesthesia a loading dose — 8 ml of 0.2% ropivacaine was administered and followed by continuous infusion at rate 4 mL/h for 48 hours. Aside from CWI, all patients received systemic anesthesia: acetaminophen 4000 mg per os, ketorolac 90 mg IV and rescue opioid — tramadol up to 400 mg (as-needed) daily. Breast milk (colostrum) samples were collected after 24 and 48 hours after a loading dose and were analyzed by gas chromatography with a mass selective detector for total ropivacaine concentrations.

Results. The number of patients included in the study was 8. During the study neither cases of the onset of symptoms associated with systemic toxicity of ropivacaine, nor allergic and infectious complications, were observed. The mean +- SD Cmax total colostrum ropivacaine concentration was 0.005 ± 0.002 (0.002 – 0.007) μg / ml.

Conclusion. In this limited sample, increasing the concentration or/and infusion rate seems to be a safe (for both mother and newborn) alternative or adjunct to standard systemic analgesia after CS in order to provide proper postoperative pain control.

Regional Anesthesia and Acute Pain Management. 2020;14(3):149-155
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Postoperative anesthesia for vitreoretinal surgery in children

Oleshchenko I.G., Zabolotskii D.V., Iureva T.N., Zaika V.A., Koriachkin V.A.


Vitreoretinal surgery for retinal detachments in children is an effective, sometimes the only method to restore vision. As practice shows, the use of minimally invasive regional techniques is increasingly used for combined anesthesia in ophthalmic surgery in children. In the postoperative period, the use of blockades can provide prolonged analgesia, thereby improving the child’s comfort level after the surgery. All types of blockades in ophthalmology have certain risks, but the pterygopalatine blockade has not any, since it is performed outside the eye structures. The research of the use of the pterygopalatine blockade after surgery in children is important not only for creating prolonged analgesia, but also for reducing vegetative reactions that can complicate the recovery period.

Purpose of the study is to increase the pain management efficacy in the postoperative period in children who have undergone extensive surgery for retinal detachment.

Materials and methods. 1st group (= 32) received postoperative analgesia — pterygopalatine blockage with ropivacaine 0.5%, 2nd group (= 28) — systemic analgesia. Changes in hemodynamics and stress index in the postoperative period were evaluated. Cortisol levels in the intensive care unit was evaluated in 2 hours later. The time and frequency use of antiemetics in the occurrence of PONV were recorded. The level of patients comfort after surgery and the pain intensity were evaluated on an integral scale and on the Verbal Rating Scale (VRS) in points.

Results. The children of 1st group did not have significant changes in heart rate and SBP in the intensive care unit. In group 1, the TI decreased by 13.2% in the intensive care unit, and in group 2, the TI increased by 28.5% after 2 hours and by 88.6% after 8 hours. 2 hours after the surgery pain was 2 points in 12.5% of the patients (1st group) and 39.2% of patients (2nd group). After 8 hours, 35.7% of patients (2nd group) reported moderate pain that required medication. There were no PONV in group 1, and it occured in 28.5% of patients in group 2. In group 1, 75% of children rated the postoperative period as comfortable, and in group 2 — 21.4% (< 0,05).

Conclusion. Pterygopalatine blockade as the main method of postoperative analgesia in the early postoperative period has got a long-term analgesic effect, reducing the frequency of nausea and vomiting, improving the quality of the postoperative period in children.

Regional Anesthesia and Acute Pain Management. 2020;14(3):156-163
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Case reports

Epidural analgesia in patients with thrombocytopenia. Clinical case

Goncharova E.V., Polushin A.Y., Kucher M.A., Ermolova M.V., Zalyalov Y.R., Portnyagin I.V., Bogomolny M.P., Sokolov A.Y., Ulrikh G.E.


The article presents a clinical case of a 25-year-old patient with progressive diffuse B-cell lymphoma with lesions of the S2 nerve root, accompanied by pain syndrome that is not relieved by systemic multimodal analgesia using opioids, antiepileptic and non-steroidal anti-inflammatory drugs. Polyneuropathy, secondary immunodeficiency, thrombocytopenia grade IV refractory to platelet concentrate transfusion, Guillain-Barre syndrome, impaired the somatic status and intensified the pain syndrome. Local anesthetics epidural port was successfully implanted to improve quality of analgesia. As a result of prolonged epidural infusion of 0.2% ropivacaine with titration rate from 4 to 7 ml/hour depending on the severity of the pain syndrome, that significantly improved patient’s quality of life was achieved by reducing the intensity of pain and increasing duration of night sleep. In the early postoperative and long-term follow-up periods (14 days), there were no hemorrhagic and infectious complications associated with the use of the epidural port.

Regional Anesthesia and Acute Pain Management. 2020;14(3):164-170
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