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Vol 17, No 1 (2023)

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Original study articles

BIS-monitoring as a tool for evaluation regional anesthesia in ophthalmology: pilot study

Marova N.G., Vasilev Y.I., Pismennaia N.V.


BACKGROUND: General anesthesia in vitreoretinal surgeries may be combined with ophthalmic blocks. Prolonged sub-tenon block (PSB) in extensive surgery ensures the continuous administration of a local anesthetic into the episcleral space; however, its effectiveness has not been evaluated.

OBJECTIVE: To evaluate the effectiveness of sub-tenon block for vitreoretinal surgery in general anesthesia.

MATERIALS AND METHODS: The pilot study included 24 patients. All patients underwent retinal detachment surgery under general anesthesia with sevoflurane for >90 min. Patients were randomized into two groups. In group 1, analgesia was induced with intravenous tramadol. In group 2, general anesthesia was combined with sub-tenon block, and 1% lidocaine was used continuously. Bispectral index (BIS) monitoring was employed for anesthesia depth assessment. The mean blood pressure and heart rates were estimated for the evaluation of the oculovisceral reflex block. The Student and Wilcoxon–Bonferroni criterion was used for statistical analysis, and the statistical significance level was set at α=0.05.

RESULTS: The hemodynamic and consequently the degree of oculovisceral reflexes block had no statistically significant differences between the groups. The median BIS in groups 1 and 2 were 48.1±11.1 U and 42.6±8.2 U, respectively, and the difference between these values was statistically insignificant (p >0.05). However, in group 1, the BIS increased sharply during the laser phase. At this stage, the average BIS in groups 1 and 2 were 76.7±3.2 U and 40.4±6.9 U, respectively (p=0.001).

CONCLUSION: BIS-monitoring can be used as an indicator of the effectiveness of ophthalmic regional blocks in further studies.

Regional Anesthesia and Acute Pain Management. 2023;17(1):5-12
pages 5-12 views

Effect of epidural blockade on immune parameters in the perioperative period: randomized controlled study

Avetisian V.A., Ezugbaia B.S., Koriachkin V.A., Zabolotskii D.V., Safin R.R.


BACKGROUND: The potential benefits of anaesthesia techniques in the parameters of cellular immunity and prevention of metastasis in various types of cancer are attracting increasing attention.

OBJECTIVE: Our aim was to estimate the influence of the epidural blockade as a component of the anesthesia support on the immunity indexes in the patients operated for gastric cancer.

MATERIALS AND METHODS: 89 patients operated on for gastric cancer, divided into two groups were investigated: in the 1st group (n=27) there was general anesthesia (GA) in combination with extended epidural blockade; in the 2nd group (n=24) — GA with postoperative intravenous administration of analgesics. T-cell counts (CD3+, CD4+ CD8+, CD4+/CD8+) and cytokines (IL-4, IL-6, IL-10, INF-y and TNF-a) were determined.

RESULTS: The CD3+ T-cell levels in both groups were significantly (р <0.05) reduced immediately after surgery. On the 2nd and 3rd day the decrease in CD3+ T-cells was more pronounced (р <0.05) in the 2nd group compared to the 1st group. The content of CD4+ T-cells decreased by the 1st day of the postoperative period (р <0,05) but then gradually increased, the CD4+ level in the 1st group was significantly (р <0.05) higher than in the 2nd group. The changes of CD8+ content between the studied groups were not statistically significant. The immunoregulatory index in both groups decreased by1st day (р <0.05). On the 9th day the index in the 1st group returned to the basic values, while in the 2nd group it remained significantly lower. On the 1st and 3rd day, the levels of IL-4 and IL-6 significantly (р <0.05) increased, while in the 2nd group the levels were higher than in the 1st group (р <0.05). On the 9th day IL-4 and IL-6 indices returned to their initial values. The changes of IL-10 level had a similar pattern, while in the 1st group the rate was significantly higher (р <0.05). At all stages of investigation, the level of IFN-γ was significantly (р <0.05) higher in the 2nd group, the level of TNF-α was higher in the 1st group (р <0.05).

CONCLUSION: The use of postoperative epidural analgesia during gastric resection for malignant neoplasm is associated with a less suppressive effect on the content of subpopulations of T-lymphocytes and cytokines in comparison with intravenous administration of analgesics and may contribute to the activation of antitumor immune response. Prospective long-term studies are needed to evaluate physician epidural analgesia for oncological outcomes after surgery for gastric cancer.

Regional Anesthesia and Acute Pain Management. 2023;17(1):13-24
pages 13-24 views

Comparative analysis of the paravertebral block and epidural anesthesia in the complex of anesthetic support for laparoscopic kidney surgery: open randomized clinical study

Lapkina I.V., Ovechkin A.M., Alekseeva T.M., Kozlov V.V., Bezrukov E.A., Slusarenko R.I.


BACKGROUND: Laparoscopic kidney surgery is performed mostly under general anesthesia. Regional techniques, primarily epidural anesthesia / analgesia (EA), help improve the surgical results. However, EA is often accompanied by several complications and side effects. The thoracic paravertebral block (PVB) is considered a reasonable and effective alternative.

OBJECTIVE: To conduct a comparative analysis of the effectiveness of general anesthesia (GA) + PVB, GA alone, and GA + EA in laparoscopic kidney surgery.

MATERIALS AND METHODS: An open-label randomized clinical study enrolled 180 patients who underwent laparoscopic kidney surgery. By using an online tool (https//www, the patients were divided into three groups in a 1:1:1 ratio. Group 1 (n=60) underwent surgery under GA + PVB, group 2 (n=60) under GA, and group 3 under GA + EA. In each group, the intra-, and postoperative need for opioids, pain intensity on a visual analog scale (VAS) 1, 6, 12, and 24 h after surgery, and activation time were assessed. The results of the groups were compared. The frequency and nature of complications when performing and working with PVB were studied.

RESULTS: The intraoperative need for opioids was greater in the GA group and comparable in the GA + PVB and GA + EA groups (p=0.137). The postoperative pain in the PVB group remained consistently low (VAS score ≈2 points) during the observation period. In the GA group, it reached ≈5 points after 1, 6, and 12 h and ≈4 points 24 h after the surgery; in the EA group, it was ≈4 points (1, 6, and 12 h) and ≈3 points 24 h after the surgery. The prolonged PVB in the postoperative period significantly lowered the opioid need (p=0.045) and contributed to earlier activation of the patients (p=0.001). Under ultrasound control, PVB is safe, and effective.

CONCLUSION: The study showed that PVB in the complex of anesthetic support for kidney surgery provides an effective and safe anesthesia / analgesia and can be used as an alternative to EA.

Regional Anesthesia and Acute Pain Management. 2023;17(1):25-38
pages 25-38 views

Justification of the expediency of using harmless analgesia in bariatric surgery: prospective randomized study

Neimark M.I., Zhilin S.V.


BACKGROUND: The presence of various comorbid conditions in patients with obesity increases operational risk, and high sensitivity to sedatives and opioid drugs can contribute to their aggravation.

OBJECTIVE: To compare and evaluate two methods of perioperative analgesia, namely, multimodal without opioid and non-opioid when performing longitudinal gastric resection for patients with morbid obesity using the enhanced recovery after surgery protocol.

MATERIALS AND METHODS: A prospective randomized study of patients with morbid obesity was conducted. Depending on the type of analgesic component of anesthesia, the patients are divided into two groups. In both groups, low-flow desflurane inhalation was used; in group 1 (n=30), the technique of non-opioid analgesia was used, which included intraoperative infusion of ketamine, dexmedetomidine, lidocaine, and magnesium sulfate. In group 2 (n=30), traditional combined anesthesia using fentanyl was administered. In the postoperative period, the infusion of the above drugs continued for 10 h in group 1. Central and peripheral hemodynamic parameters, and the depth of anesthesia were studied, and TOF-monitoring was carried out. Postoperative rehabilitation was assessed based on the time of extubation, achievement of 13 points on the PARS scale, first getting up on one’s feet, appearance of overstrain, and gas discharge. Postoperative analgesia was assessed on a 10-point visual analog scale, and anesthesia-related complications were recorded.

RESULTS: Surgical intervention under low-flow inhalation anesthesia based on desflurane in combination with multimodal opioid-free analgesia reduced the need for opioid analgesics intraoperatively (in group 1, the fentanyl dose was 0.2 [01; 0.2] mg; in group 2 — 0.4 [0.3; 0.5] mg; p=0.002), provided less fluctuation of intraoperative hemodynamic parameters (AvBP: stage 1: group 1 — 102 [100; 103]; group 2 — 102 [98; 105], p=0.96; stage 2: group 1 — 93 [90; 95]; group 2 — 96 [93; 99], p=0.003; stage 3: group 1 — 95 [95; 97]; group 2 — 100 [96; 102], p <0.001; stage 4: group 1 — 95 [92; 97]; group 2 — 98 [98; 101], p <0.001; CI stage 1: group 1 — 49±2.2; group 2 — 49.5±2.2, p=0.39; stage 2: group 1 — 44.4±2; group 2 — 44.6±2.1, p=0.26; stage 3: group 1 — 45.5±2.11; group 2 — 50.6±2.8, p=0.001; stage 4: group 1 — 44.5±2.1; group 2 — 48.8±2.5 p <0.001), and contributed to a lower level of pain and faster rehabilitation. In addition, anesthesia-related complications such as postoperative nausea and vomiting, hypoxemia, and dysphoria were less frequently recorded.

CONCLUSION: The use of multimodal non-opioid analgesia contributes to a lesser fluctuation in hemodynamic parameters, a low level of postoperative pain, early activation of patients and restoration of peristalsis, and a decrease in the number of postoperative complications in patients who underwent longitudinal gastric resection for morbid obesity.

Regional Anesthesia and Acute Pain Management. 2023;17(1):39-49
pages 39-49 views

Endocrine and metabolic monitoring for anesthesia care in orthopedic trauma surgery on the lower extremities of children: prospective comparative study

Rozin Y.E., Marochkov A.V.


BACKGROUND: Standard anesthesia monitoring during surgery only indirectly allows us to estimate achieving an effective level of analgesia sufficient to protect the patient from surgical trauma. Recently, studies have analyzed cortisol, glucose, and lactate levels during surgery in children and adults; however, data presented remain inconsistent.

OBJECTIVE: This study aimed to conduct a prospective comparative analysis of endocrine metabolic dynamic rates in orthopedic trauma surgery on the lower extremities of children.

MATERIALS AND METHODS: The study included 39 children who underwent orthopedic trauma surgery. They were divided into two groups: group 1 (n=17) underwent multicomponent balanced general anesthesia, and group 2 (n=22) received combined anesthesia (multicomponent balanced general anesthesia combined with regional blockade of the sciatic and femoral nerves). The dynamics of cortisol, glucose, and lactate indicators at three stages of the perioperative period, total amount of fentanyl, and need for an inhalation anesthetic were examined.

RESULTS: Indicators of cortisol, glucose, and lactate in mixed venous blood during surgery did not exceed the age norm in both groups. In group 1, cortisol, glucose, and lactate levels did not statistically differ at all stages of the study. In group 2, cortisol and lactate levels increased at the fifth stage (traumatic stage) of surgery, and lactate levels increased in the sixth stage (end of surgery). In intergroup comparison, the lactate level at the traumatic stage of surgery was higher in group 1 than in group 2 (p=0.048). Cortisol and glucose levels at the stages of the study did not differ significantly. The total amount of fentanyl for pain relief in group 1 was 4.1 [3.3; 5.0] µg/kg, which was 8.2 times higher than that in group 2, with 0.5 [0.4; 0.53] µg/kg (p <0.0001).

CONCLUSION: Both anesthesia methods ensure stable levels of cortisol, glucose, and lactate, and adequate level of analgesia at all stages of surgery; however, the use of a conduction blockade as a component of combined anesthesia provides more pronounced antinociceptive protection and reduces surgical stress in children.

Regional Anesthesia and Acute Pain Management. 2023;17(1):51-58
pages 51-58 views

Prolonged blockade of the sciatic nerve in the treatment of pain in patients with chronic limb-threatening ischemia: prospective longitudinal clinical study

Orudzheva S.A., Ushakov A.A., Magomedova S.D.


BACKGROUND: Systemic multimodal analgesia does not always relieve ischemic pain, and the side effects of its components may be intolerable in patients with comorbid and physically debilitation with chronic limb-threatening ischemia (CLTI). An alternative effective and safe method of pain relief for patients with CLTI is needed.

OBJECTIVE: To evaluate the efficacy and safety of prolonged popliteal sciatic nerve block in patients with CLTI at the stages of treatment.

MATERIALS AND METHODS: A prospective clinical study was performed in 31 patients with CLTI. Pain intensity was assessed by a numerical rating scale at the stages of treatment: (1) on admission, (2) presence of systemic multimodal analgesia (paracetamol, ketoprofen, tramadol, and morphine), (3) after catheter insertion to the popliteal sciatic nerve and prolonged nerve block with 0.5% ropivacaine solution, (4) after revascularization without anesthesia, (5) after revascularization in the presence of nerve blockade, and (6) upon discharge. Catheter insertion was performed under ultrasound control and neurostimulation. Pain intensity, frequency of insomnia, and forced lowering of the limb, need for narcotic analgesics, and patient satisfaction with treatment were assessed.

RESULTS: Regional block before surgery provided better pain relief than systemic multimodal analgesia (p <0.001) and reduced the need for narcotic analgesics (p <0.001). Insomnia was observed less frequently with prolonged blockade of the sciatic nerve than with systemic multimodal analgesia (p <0.05), as well as forced lowering of the limb (p <0.05). Revascularization of the lower extremity has an analgesic effect; however, pain relief is required for most patients. Pain relief through sciatic nerve block at all stages of CLTI treatment, sleep normalization, and freedom from forced posture improved the quality of life and satisfaction with treatment. No complications associated with the regional blockade were recorded.

CONCLUSION: Prolonged popliteal sciatic nerve block effectively relieves pain in patients with CLTI, is safe, and can be an alternative to systemic anesthesia.

Regional Anesthesia and Acute Pain Management. 2023;17(1):59-69
pages 59-69 views

Case reports

Effect of sevoflurane on the pain syndrome and course of acute pancreatitis: сlinical cases

Sitkin S.I., Emelyanova L.V., Pozdnyakov O.B.


BACKGROUND: Acute pancreatitis is a potentially life-threatening disease, which is based on a severe inflammatory process and enzymatic autolysis of the pancreas. Currently, there is no effective medical treatment for acute pancreatitis. Its therapy is based on early infusion, adequate anesthesia, enteral nutrition, antibiotic therapy for infected pancreatic necrosis, and sanitizing procedures for the development of purulent and septic complications. In the last decade, experimental, and clinical studies have proven the powerful anti-inflammatory effect of the inhalation anesthetic sevoflurane. Sevoflurane reduces inflammation, both by blocking the nuclear factor kappa-bi and reducing the release of reactive oxygen species and pro-inflammatory cytokines.

CLINICAL CASES DESCRIPTION: We used inhaled sevoflurane in three patients with acute pancreatitis. For one inhalation, 5 mL of sevoflurane was used and poured into a 200-mL container. The duration of one inhalation was approximately 40 min, during which time the anesthetic had completely evaporated. The maximum concentration of sevoflurane in exhaled air reached 0.4–0.5%, which did not cause the patient to fall asleep. Inhalations were performed three times a day for 2 days. In all patients, the pain syndrome decreased by three times according to the visual analog scale on day 1. The level of amylase on day 2 decreased by 2.5 times. The leukocyte count decreased by 20%. On day 2, all patients developed intestinal motility, and the patients were transferred from the anesthesiology-reanimation department to the surgical department. All the patients recovered.

CONCLUSION: The inhalation of sevoflurane alleviated the pain syndrome, reduced amylase levels, and improved intestinal motility in acute pancreatitis.

Regional Anesthesia and Acute Pain Management. 2023;17(1):71-76
pages 71-76 views

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