Open Access Open Access  Restricted Access Access granted  Restricted Access Subscription or Fee Access

Vol 18, No 4 (2024)

Cover Page

Full Issue

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription or Fee Access

Reviews

The past, present, and future of anesthetic management in total knee arthroplasty: a descriptive literature review

Seregina M.A., Balikova D.I., Scholin I.Y., Suryakhin V.S., Koriachkin V.A.

Abstract

The number of patients with osteoarthritis of large joints in the Russian Federation may reach 4 million, with the demand for knee arthroplasty estimated at approximately 300,000 procedures annually. Improved osteoarthritis diagnostics, increased life expectancy, and advancements in prosthetic technologies have driven the rise in knee arthroplasties. However, unresolved challenges related to anesthetic management for such surgeries underscore the importance of effective pain management during total knee arthroplasty (TKA) from both scientific and practical perspectives. Anesthetic techniques for TKA have evolved significantly over time. Advances in medical knowledge and technology have led to the development and refinement of various anesthetic approaches aimed at improving patient outcomes. Historically, general and infiltration anesthesia, along with neuraxial blocks, were used. The introduction of ultrasound-guided (US-guided) techniques has expanded the use of peripheral nerve blocks. Current practices include multimodal general anesthesia, spinal anesthesia, and, less commonly, epidural anesthesia. US-guided techniques encompass obturator nerve block, anterior-medial and posterior-lateral capsule blocks, periarticular infiltration, “four-in-one” block, and selective genicular nerve blocks, among others. Future directions in anesthetic management for TKA include evaluating the clinical efficacy of radiofrequency catheter ablation and cryoablation. Additionally, addressing the significant challenge of rebound pain by identifying its causes and developing effective treatment strategies is essential. The global increase in TKA volumes presents a challenge for anesthesiologists and surgeons, emphasizing the need to further advance regional anesthesia techniques to improve recovery quality following surgery.

Regional Anesthesia and Acute Pain Management. 2024;18(4):298-311
pages 298-311 views

Paravertebral block in pediatric cardiac surgery: a descriptive literature review

Tarasov E.M., Khinovker V.V., Svalov A.I., Koriachkin V.A., Fedorov .A.

Abstract

This review aimed to describe modern methods of perioperative analgesia in pediatric cardiac surgery, with a particular focus on the application of regional anesthesia for acute pain management and its effects on postoperative recovery. A literature search was conducted from August 15, 2023, to March 1, 2024, using the PubMed (MEDLINE) database and the Cochrane Library. Fifty-one articles were identified and formed the basis of this review. The reviewed literature indicates that regional anesthesia techniques, particularly paravertebral block (PVB), demonstrate high analgesic efficacy in the perioperative period of pediatric cardiac surgery and are associated with fewer complications related to high-dose opioid use. Incorporating PVB into postoperative pain management protocols reduces the risk of emergence agitation, ensures more stable hemodynamics post-extubation in thoracic surgery patients, and improves postoperative pulmonary function indicators. Compared to thoracic epidural analgesia, PVB has lower failure rates and a reduced risk of arterial hypotension, nausea, vomiting, and urinary retention. Evidence from pediatric oncology also supports the efficacy and safety of PVB.

Regional Anesthesia and Acute Pain Management. 2024;18(4):312-322
pages 312-322 views

Original study articles

Spinal anesthesia as a method of anesthetic support for arthroscopic cruciate ligament reconstruction: a single-center prospective cohort study

Gorelov D.V., Ovechkin А.М., Babayants A.V., Ignatenko O.V.

Abstract

Background: The annually increasing number of arthroscopic interventions on cruciate ligaments, especially in outpatient settings, necessitates identifying the most rational methods of anesthetic support for such procedures.

Aim: To evaluate spinal anesthesia (SA) as the method of choice for anesthetic support in arthroscopic cruciate ligament reconstruction.

Materials and methods: This single-center prospective cohort study included 52 patients who underwent arthroscopic cruciate ligament reconstruction under SA. Postoperative outcomes were assessed by measuring pain intensity at rest and during movement at 4, 8, 12, 16, 20, and 24 hours postoperatively using the visual analog scale (VAS). The need for opioid analgesics, their total dose, time to the first analgesic request, motor block recovery time (Bromage scale to Bromage-1), and time to first ambulation were recorded. Intraoperative hemodynamic and pulse oximetry parameters, SA performance time, duration of anesthesia and surgery, total dose of non-steroidal anti-inflammatory drugs (NSAIDs) during hospitalization, complications, adverse anesthesia reactions, and hospital stay duration were also evaluated. Additionally, patient satisfaction with anesthesia and postoperative pain management quality was assessed.

Results: Significant differences in pain levels at rest and during mobilization were observed (p <0.001, R=0.8). A total of 82.6% (n=43) of patients required opioid analgesics postoperatively, with 18% (n=8) needing administration twice or more. The frequency of opioid use was directly proportional to pain severity (p <0.001, R=0.7). The first request for analgesics occurred, on average, at 178 minutes, with motor block recovery at 134 minutes. First ambulation was recorded, on average, more than 3 hours after surgery.

Conclusion: Severe postoperative pain, the inability to achieve early mobilization, adverse anesthesia effects, and the transition of arthroscopic procedures to “day surgery” status emphasize the need for alternative anesthesia techniques that overcome SA shortcomings and provide prolonged postoperative pain relief.

Regional Anesthesia and Acute Pain Management. 2024;18(4):323-333
pages 323-333 views

Pemedication in preventive analgesia, achievement of psycho-emotional comfort, and alleviation of preoperative anxiety in elective surgery: a prospective controlled study

Shen N.P., Ayanova I.M., Magadeev I.G.

Abstract

Background: The role of premedication in preventive analgesia, achieving psycho-emotional comfort, and alleviating preoperative anxiety in elective surgery remains insufficiently studied. This is evidenced by the lack of clear recommendations regarding its timing and vague criteria for its administration.

Aim: To evaluate the effects of premedication on subjective and clinical outcomes during the perioperative period in elective surgery patients.

Materials and methods: A prospective controlled study was conducted at two multidisciplinary clinics in Tyumen from December 12 to 20, 2023. Only patients seeking elective surgical care were included. After screening based on eligibility criteria, 42 patients scheduled for elective surgical procedures on the designated study day were enrolled. A novel checklist was developed for the study, and descriptive statistics and correlation analyses were employed.

Results: Evening premedication was more effective than morning premedication in reducing fear and anxiety (r=0.51 for evening and r=0.32 for morning premedication). Evening premedication not only alleviated preoperative anxiety but also reduced pain impulse intensity from the surgical wound under standard postoperative pain management (p=0.0001). Additionally, statistically significant differences (p=0.03) in glycemia levels indicated better adaptation to surgical stress, supporting the use of evening premedication as a method of preventive analgesia, which was not observed with premedication administered immediately before the procedure.

Conclusion: This pilot study demonstrated the significant role of evening premedication in mitigating adverse perioperative phenomena in elective surgery patients. Attention to the timing and role of premedication may enhance treatment effectiveness and improve patient comfort during hospitalization.

Regional Anesthesia and Acute Pain Management. 2024;18(4):334-343
pages 334-343 views

Ultrasound-assisted quadratus lumborum block as a method of postoperative analgesia in total hip arthroplasty: a single-center prospective randomized study

Ezhevskaya A.A., Molchanov E.A., Ignatev S.M., Baturina E.A., Fedorov M.E.

Abstract

Background: Using regional postoperative analgesia in total hip arthroplasty (THA) minimizes pain and opioid consumption while preserving patient mobility. Quadratus lumborum block (QLB) has demonstrated these effects in abdominal surgery; however, its application in trauma and orthopedics remains understudied.

Aim: To evaluate the efficacy and safety of combining lateral and posterior approaches to QLB as a component of multimodal analgesia for postoperative pain management after THA.

Materials and methods: This single-center prospective randomized study included 153 patients aged 48–65 years undergoing THA. Participants were divided into two groups: Group 1 received preoperative QLB, while Group 2 served as the control. All patients underwent spinal anesthesia with intravenous sedation and received analgesia as part of multimodal pain management. Postoperative outcomes on the first day were assessed by measuring pain intensity using the visual analog scale (VAS) at rest and during mobilization, walking distance, opioid consumption, and the incidence of side effects from opioid use.

Results: VAS pain scores at 6, 12, and 24 hours postoperatively were significantly lower in the QLB group compared to the control group (p <0.001). Walking distance also differed: Group 1 patients walked 10 [5; 20] m within the first 12 hours and 40 [30; 50] m within 24 hours, compared to 5 [0; 10] m and 30 [20; 40] m, respectively, in the control group (p <0.017). In Group 1, 28 (50.67%) patients did not require opioids, and 37 (49.33%) needed them only once. In the control group, all patients required opioids, with 38 (50.67%) requesting repeated doses (p <0.001).

Conclusion: This study demonstrated that QLB effectively reduces pain, opioid consumption, and associated complications while increasing mobility, confirming its efficacy and safety as a postoperative analgesic method for THA.

Regional Anesthesia and Acute Pain Management. 2024;18(4):344-355
pages 344-355 views

Experience with an opioid peptide (tyrosyl-D-arginyl-phenylalanyl-glycine amide) in oncology: a comparative randomized clinical study

Lukonina T.D., Khoronenko V.E., Abuzarova G.R., Malanova A.S., Ageeva A.A.

Abstract

Background: The application of tyrosyl-D-arginyl-phenylalanyl-glycine amide, a highly specific μ1-opioid receptor agonist, represents a promising approach for managing acute postoperative pain.

Aim: To evaluate the efficacy and safety of tyrosyl-D-arginyl-phenylalanyl-glycine amide in oncology patients, depending on the type of anesthesia used for various surgical interventions.

Materials and methods: A comparative randomized clinical study included 80 patients aged 29–86 years [median age (Me) 66 years, interquartile range (Q1; Q3) 59–71 years], of whom 46 (57.5%) were men and 34 (42.5%) were women, classified as American Society of Anesthesiologists (ASA) physical status I–III. These patients underwent planned surgical treatment for oncological diseases. Patients received either multimodal combined general anesthesia with mechanical ventilation in the control group (Group K, n=40) or combined anesthesia (general+epidural/intercostal block for thoracic surgeries) in the comparison group (Group C, n=40). All patients were administered a standardized postoperative systemic analgesia protocol based on tyrosyl-D-arginyl-phenylalanyl-glycine amide at a dose of 4 mg 3 times per day. The first dose was administered when pain intensity exceeded 3 points at rest and 4 points during movement on the Numeric Rating Scale (NRS). Pain intensity was assessed at rest and during movement at predetermined time points: 15, 30, 45, 60, 120, and 240 minutes after the first dose.

Results: Baseline pain intensity at rest (NRS) was higher in Group K compared to Group C [Me=6, (Q1; Q3)=(5; 5) and (5; 6), respectively; p=0.038]. While initial pain intensity during movement was similar between groups (Me=7 points), the interquartile range was greater in Group K [(Q1; Q3) = (6; 8)] compared to Group C [(6; 7); p=0.045]. Lower pain scores were observed in Group C at 45 and 60 minutes at rest (p=0.005 and p=0.008, respectively) and at 30 minutes during movement (p=0.036).

Conclusion: The combination of tyrosyl-D-arginyl-phenylalanyl-glycine amide with regional perioperative blocks is an optimal method for managing acute pain in the early postoperative period for patients undergoing complex and traumatic oncological surgeries.

Regional Anesthesia and Acute Pain Management. 2024;18(4):356-372
pages 356-372 views

Efficacy of ultrasound-assisted pterygopalatine block using a posterior-to-anterior subzygomatic approach in eye enucleation: a prospective randomized comparative study

Oleshchenko I.G., Zabolotskii D.V., Mankov A.V., Koriachkin V.A.

Abstract

Background: Pterygopalatine block (PPB) is widely indicated in ophthalmology due to its simultaneous impact on sympathetic, parasympathetic, and nociceptive innervation. Ultrasound (US) guidance enhances block accuracy; however, clinical data on the efficacy of US-assisted PPB using different approaches remain limited.

Aim: To compare the efficacy of US-guided PPB using posterior-to-anterior subzygomatic and suprazygomatic approaches in patients undergoing eye enucleation.

Materials and methods: A prospective randomized study was conducted. For postoperative analgesia, PPB was performed in Group 1 (n=30) using the posterior-to-anterior subzygomatic approach and in Group 2 (n=30) using the suprazygomatic approach. The time required to perform the block, onset of analgesia, changes in arterial blood pressure (BP) and heart rate (HR), and technical aspects of block execution were evaluated.

Results: The interval between block administration and the onset of analgesia was significantly shorter in Group 1 (5.3±1.0 minutes) compared to Group 2 (10.1±1.4 minutes, p=0.041). Significant differences were also observed in the time to decreased skin sensitivity in the infraorbital area and time to pain relief: 8.9±0.9 and 13.5±0.7 minutes in Group 1 versus 14.4±1.2 and 19.6±1.7 minutes in Group 2 (p=0.037 and p=0.034, respectively). Mean arterial pressure and HR were lower in Group 1 (91.2±6.5 mmHg and 88.5±5.2 bpm) compared to Group 2 (101.1±6.6 mmHg and 105.3 ± 8.4 bpm, p=0.001). During the suprazygomatic PPB (Group 2), 53.3% (n=16) of patients reported discomfort, with a mean pain score of 2.3±0.5 on the numeric rating scale.

Conclusion: For managing pain after eye enucleation, ultrasound-assisted PPB using the posterior-to-anterior subzygomatic approach is the method of choice. Compared to the suprazygomatic approach, it provides faster onset of effective analgesia, greater patient comfort, and improved safety.

Regional Anesthesia and Acute Pain Management. 2024;18(4):373-381
pages 373-381 views

Comment

Review of the monograph of Evgenii T. Rostomashvili «Spinal, epidural and caudal anesthesia», St. Petersburg, 2023

Strashnov V.I., Koriachkin V.A.

Abstract

This peer-reviewed monograph is devoted to caudal epidural anesthesia. The book gives the background to the origin of the method, describes the anatomical basis, the technique and the functional effects of the anesthesia. The author presents his own results of using caudal epidural anesthesia in both surgical and therapeutic practice. Complications and failures that may occur during caudal epidural anesthesia are presented. The monograph is of practical interest for postgraduate students and anesthesiologists.

Regional Anesthesia and Acute Pain Management. 2024;18(4):382-385
pages 382-385 views