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Vol 16, No 3 (2022)

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Preliminary outcomes of the COVID-19 pandemic: a new chronic pain profile

Shen N.P., Logvinenko V.V., Tsiryatieva S.B., Osin V.I., Masserov A.A.


In summing up the preliminary results of the COVID-19 pandemic that has not yet ended, modern research pays much attention to the so-called “post-COVID” syndrome, which includes the long-term consequences of the disease. In English, symptoms are reported as “long COVID”, “post-acute COVID”, or “chronic post-COVID syndrome” and are described as symptoms of fatigue, respiratory disorders, memory, and sleep problems. Symptoms such as muscle pain and decreased endurance when performing habitual physical exertion are mentioned much less often. Meanwhile, among the complaints of those who have been ill, this symptom is present quite often, reducing the quality of life and tolerability of normal physical exertion. This review aimed to provide an in-depth study of a new type of the chronic myofascial pain syndrome after COVID-19, i.e., the frequency of occurrence, causes of the development, and pathophysiology of chronic pain syndrome associated with COVID-19 and manifested as fibromyalgia of various localizations. To answer the questions posed, the authors searched for information in four electronic databases. The key search terms used were “COVID-19”, “long COVID,” and “signs and symptoms of pain syndrome”. A review of current literature data has shown that close study and dynamic monitoring of patients who had COVID-19 can contribute to further deciphering the pathophysiological mechanisms of the development of its long-term consequences and provide answers to questions on the prevention and treatment of chronic pain syndrome in this patient cohort.

Regional Anesthesia and Acute Pain Management. 2022;16(3):171-183
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Original study articles

Features of postoperative pain relief in patients with a low level of consciousness: a prospective randomised study

Al-Haddad H.A., Petrova M.V., Kolesov D.L.


AIM: To determine the possibility of using analgonociception monitoring (analgesia nociception index, ANI) to assess the need for postoperative analgesia in patients with prolonged impairment of consciousness.

MATERIAL AND METHODS: This pilot prospective randomized study enrolled 34 consecutive patients with chronic impairment of consciousness (vegetative state/minimal state of consciousness) who underwent neurosurgical interventions. Randomization was made by the envelope method for the grouping of the patients: study group (SG, n=17), received anesthesia with intravenous paracetamol 1000 mg according to ANI in the postoperative period; control group (CG, n=17), without additional anesthesia in the postoperative period. Patients with arrhythmias were excluded. The groups are comparable in terms of the main clinical parameters (all parameters p >0.05). The ANI (MetroDoloris device, France) was recorded at 1, 4, 8, 12, and 24 h after surgery. The valuation was based on the revised scale for assessing pain in a coma, i.e., Nociception Coma Scale–Revised (NCS-R) [7], after 4, 12, and 24 h.

RESULTS: An intragroup comparison of the changes in ANI during postoperative day 1 showed an adequate level of pain relief (60.1 [55.3–62.5]), whereas in the group without postoperative analgesia with paracetamol, by 4 h after the operation, ANI dropped to the lower limit (46.3 [40.2–51.9]). In an intergroup comparison in the first 8 h after surgery, ANI was significantly higher than in the group without anesthesia (p=0.04) and had values of >55, which indicates the absence of pronounced vegetative reactions indicating the presence of pain. From 12 o’clock, the values are leveled out, not going beyond the limits of indicators of inadequate anesthesia (p=0.69). When assessing nociception on the NCR-R scale during the postoperative day in both groups, a tendency to the appearance of weak autonomic responses was observed (6 [5; 8] in SG and 6 [5; 7] in CS, respectively), which did not differ significantly. The presence of pain 4 h after surgery was confirmed by increased levels of cortisol and salivary alpha-amylase in patients without postoperative analgesia (p=0.03).

CONCLUSION: No generally recognized and available evidence-based instrumental methods are available for the assessment of pain intensity in patients with chronic impairment of consciousness. There is no single position of the professional community on the need for postoperative analgesia in such patients. Further studies to evaluate the effectiveness of using the ANI Metro Doloris monitoring system with a significant number of observations will lead to the determination of adequate perioperative analgesia regimens in patients with various forms of prolonged impairment of consciousness.

Regional Anesthesia and Acute Pain Management. 2022;16(3):185-193
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Effect of the method of anesthetic aid on cellular immunity in periprosthetic infection of the hip joint: : a prospective open randomized study

Kazanin A.A., Zagrekov V.I., Lebedev M.Y., Nargizyan A.Z., Mitrofanov V.N., Komarov R.N., Presnov D.V.


BACKGROUND: Periprosthetic infection after primary hip replacement is a serious complication. For the anesthetic support of revision operations, both general and neuroaxial anesthesia methods can be used. The question of choosing an anesthetic aid that, with adequate modulation of the operational stress response, would have a minimal immunosuppressive effect is relevant.

AIM: To examine the effect of general and combined spinal–epidural anesthesia during revision operations in patients with periprosthetic hip joint infection on the parameters of cellular immunity.

MATERIALS AND METHODS: An open prospective randomized study was performed on 25 patients (11 women and 14 men). The patients underwent surgical interventions of revision prosthetics with the replacement of all components of the prosthesis. Group 1 (n=10) underwent general anesthesia (GA), and group 2 (n=15) underwent surgery under combined spinal–epidural anesthesia (CSEA). The indices of cellular immunity, namely, CD4+, CD8+, CD4+/CD8+, and B-lymphocytes, were evaluated. Blood sampling was performed in the morning on the day of surgery and then on days 1, 3, 5, and 7 after surgery.

RESULTS: The CD4+ (%) level in the CSEA group was significantly higher than in the GA group on days 3 and 7 after surgery (p <0.05). Changes in the percentage of CD8+ lymphocytes, the immunoregulatory index, and the percentage of B-lymphocytes between the groups had no statistically significant differences.

CONCLUSION: The CD4+ (%) level in the CSEA group was significantly higher than that in the GA group on days 3 and 7 after surgery (p <0.05). Statistically significant differences in the dynamics of CD8+, immunoregulatory index, and B-lymphocytes were not found, which may indicate a lesser effect of the type of anesthesia on these indicators.

Regional Anesthesia and Acute Pain Management. 2022;16(3):195-204
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Combination of peripheral blocks as a part of enhanced rehabilitation in total knee replacement: a prospective comparative open randomized study

Manevskiy A.A., Sviridov S.V., Builova T.V., Torpudzhiyan M.A., Borzova N.U., Tarbushkin A.A., Serebryakov A.B., Askerov S.M., Dzeytova B.M.


BACKGROUND: The patient’s recovery after total knee replacement (TKR) is long and is associated several potentially serious complications. The optimal solution to this problem is the introduction of regional blocks of the lower limb into anesthesiologic practice, which can contribute to enhanced rehabilitation and fewer complications.

AIM: To perform a prospective comparative analysis of the anesthesia outcomes of patients who received a combination of prolonged femoral nerve blockade (CFNB) with catheter insertion and infiltration between the popliteal artery and capsule of the knee (IPACK), with the results in patients receiving prolonged epidural analgesia (PEA) as postoperative analgesia for TKR.

MATERIALS AND METHODS: Eighty patients were included and distributed according to the required planned surgical intervention (TKR). The duration of the inclusion period was 3 months (from March to May 2022). Patients were observed up to 48 h after surgery, with control points every 8 h. The patients were divided into two groups: group 1 (PEA, n=40) underwent subarachnoid anesthesia in combination with PEA, and group 2 (n=40) underwent subarachnoid anesthesia as a combination of CFNB and IPACK. To compare the groups, the following main indicators were used: severity of pain syndrome (visual analog scale [VAS], from 0 to 10 cm), muscle strength on the Medical Research Council (MRC) scale, duration of patients’ stay in the intensive care unit, duration of hospitalization, and presence of postoperative complications.

RESULTS: The highest average score for VAS was recorded at 32 h in group 1, and it was 3.6 cm. The lowest average score for VAS (1.1–1.2 cm) was noted in the first 8 h and after 48 h in group 1. In group 2, this value was 0.9–1.5 cm in the first 16 h, and at 48 h, the pain syndrome was more pronounced in group 2, making up 2 cm on VAS. Compared with the PEA group, the CFNB group had statistically higher values of the indicators of the motor strength of the leg muscles on the MRC scale at all stages of the study. The PEA group stayed in the intensive care unit statistically significantly longer than the PBN group: 210 (189–260) and 180 (154–185) min, respectively (p <0.001).

CONCLUSION: The results of this study showed that the use of multimodal analgesia as a combination of CFNB and IPACK is a reliable anesthetic support for TKR, with an efficiency not inferior to classical epidural analgesia. The use of this combination of peripheral blockades contributes to the early activation and rehabilitation of patients after TKR.

Regional Anesthesia and Acute Pain Management. 2022;16(3):205-217
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Comparison of methods of analgesia in patients after pancreatic surgery: a cohort retrospective study

Ezugbaia B.S., Fedorov S.A., Avetisian V.A., Nikitenko E.Y., Sizov V.A., Kamnev S.A., Koriachkin V.A.


AIM: To compare the effectiveness of postoperative analgesia by methods of epidural blockade (EB) and rectus sheath block (RSB) in the early postoperative period in patients who underwent pancreatic surgery.

MATERIALS AND METHODS: A retrospective analysis of inpatient case histories of patients after pancreatic surgery at JSC Ilyinsky Hospital for the period from 2019 to 2021 (n=92) was conducted. For the study, 78 cases were selected, which were divided into two groups: the first group (n=46) received EB with a local anesthetic in the postoperative period, and the second group (n=32) underwent RSB followed by the introduction of a local anesthetic solution.

RESULTS:The level of pain on the visual analog scale was statistically significantly higher in the first group on day 1(1.07 [0.50–1.80] and 0.48 [0.08–1.13], respectively, p=0.013) and day 2 (0.82 [0.25–1.33] and 0.33 [0.06–0.75], respectively, p=0.021), and no differences were found on day 3 (p=0.060). The frequency of additional use of opioid analgesia did not differ between the study groups (day 1, p=0.233; day 2, p=0.570; and day 3, p=0.092 The use of norepinephrine infusion in the early postoperative period (p=0.842), daily and cumulative water balance (day 0, p=0.851; day 1, p=0.883; and day 2, p=0.319; day 3, p=0.718; and cumulative balance, p=0.707), and verticalization time (p=0.800) also showed no significant difference.). Orthostatic reactions during early mobilization were noted significantly more often in the EB group than in the RSB group (n=10, 21.7%; n=1, 3.2%, respectively; OR 8.333, 95% CI 1.008–66.667, p=0.042). The appearance of the first stool was more common in the EB group (3 [2–4] days vs. 4 [3–5] days in the RSB group, p=0.027). No statistically significant difference was found between the groups in the development of infectious complications (p=1.000), gastrostasis (p=0.144), in-hospital mortality rate (p=0.460), ICU days (p=0.305), and lengths of stay (p=0.776).

CONCLUSION: The data obtained in the study show the comparability of the use of analgesia methods, such as EB and RSB in patients who underwent pancreatic surgery.

Regional Anesthesia and Acute Pain Management. 2022;16(3):219-230
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Efficacy of regional anesthesia in episcleral surgery: a randomized controlled double-blind clinical study

Oleshchenko I.G., Mankov A.V., Belyaev S.S.


BACKGROUND: Surgical interventions for severe fundus diseases associated with diabetes mellitus, proliferative processes against the background of retinal detachment, and acute inflammatory diseases require the development of multimodal algorithms to provide sufficient analgesic and anti-inflammatory effects.

AIM: To evaluate the efficacy of combined pterygopalatine blockade (PPB) and retrobulbar blockade (RBB) in patients with episcleral retinal detachment surgery.

MATERIALS AND METHODS: The study included 100 patients who underwent episcleral surgery for retinal detachment. All patients were randomized into two groups: group 1 (retrobulbar blockade, n=50) and group 2 (pterygopalatine blockade in combination with retrobulbar blockade, n=50). The level of akinesia, volume of local anesthetic, consumption of analgesics, pain, and postoperative nausea and vomiting (PONV) were evaluated.

RESULTS: In group 2, only 12% of the patients were prescribed promedol 2% intraoperatively, which is significantly lower than that in group 1 (p=0.463). In group 2, the pain level 8 h after surgery according to the verbal sensation scale was 0.8±0.63. In group 1, the average pain score was 1.69±1.8 (p=0.558). PONV was observed in 4% of the patients in group 1. In group 2, no PONV occurred (p=0.563).

CONCLUSION: The combination of PPB and RBB allows for controlling not only pain sensitivity but also vegetative, motor, and neuroendocrine manifestations associated with pain both in the intraoperative and early postoperative periods.

Regional Anesthesia and Acute Pain Management. 2022;16(3):231-239
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Significance of ultrasound navigation during central venous catheterization in children with scoliotic spinal deformity: a prospective observational single-centre study

Smirnov I.V., Tsypin L.E., Lazarev V.V., Batyrova Z.K., Strunin O.V.


BACKGROUND: Surgeries to correct scoliotic spinal deformity (posterior corrective transpediculocorporal fusion) are classified as highly traumatic, are accompanied by significant blood loss, and require reliable venous access. Central vein catheterization is an important part of patient management and is a successful and safe procedure.

AIM: To evaluate the effectiveness of ultrasound navigation during central venous catheterization in patients with severe and super-severe scoliotic spinal deformity.

MATERIALS AND METHODS: A single-center prospective study included 52 patients aged 6 to 18 (median age 13.2) years undergoing surgical treatment to correct grade IV scoliotic spinal deformity. Patients underwent catheterization of the internal jugular vein under ultrasound navigation using an ultrasound scanner with a linear sensor and a frequency of 7–13 MHz. The procedures were performed by one operator. The following were assessed: anatomy of the neurovascular bundle, relative position of the vessels relative to each other, size of the internal jugular vein in a horizontal and Trendelenburg positions, frequency and time of the procedure, and complications during puncture and catheterization.

RESULTS: In patients with severe scoliotic deformity of the spine, an atypical location of neck vessels was noted in every fifth patient (13.46%). The peculiarity of the location of the vessels was associated with congenital developmental anomalies. The most common anomaly in the location of the vessels relative to each other was the medial location of the internal jugular vein relative to the carotid artery. In one patient, the passage of the internal jugular vein at a considerable distance from the carotid artery was revealed, which made it impossible to puncture according to anatomical landmarks. The average diameter of the internal jugular vein in the horizontal position was 6.2±0.9 mm. In the Trendelenburg position, the diameter was 9.08±1.5 mm. The average duration of the procedure was 92 seconds (±70). Taking into account the use of ultrasound navigation during catheterization of the internal jugular vein, no early and late complications occurred.

CONCLUSION: The use of ultrasound navigation for central venous catheterization during surgical treatment of severe and super-severe scoliotic deformities of the spine is a safe and essential method. The Trendelenburg position allows for better visualization of the jugular vein and facilitates its puncture and catheterization. The use of ultrasonography during invasive vascular manipulations allows for minimizing the number of failed catheterizations and avoiding complications, which improves the efficiency of medical care and increases the level of comfort and safety for the patient.

Regional Anesthesia and Acute Pain Management. 2022;16(3):241-249
pages 241-249 views

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