The implementation of enhanced recovery after surgery (ERAS) protocols has led to increased interest in nonintubated video-assisted thoracoscopic surgery (NIVATS), especially in patients with compromised pulmonary function. We present a case of a 62-year-old female with stage IIIA breast cancer and pulmonary bronchiectasis who underwent right-sided wedge resection via NIVATS. A two-level thoracic paravertebral block (TPVB) at T4 and T6 using 0.4% isobaric bupivacaine with epinephrine was performed, resulting in sensory block from T2 to T7. An intrathoracic vagal block with 0.5% bupivacaine was administered to prevent cough. Sedation was maintained with dexmedetomidine and remifentanil. Surgery lasted 83 minutes with no complications. Postoperatively, pain was minimal (NRS 0–2), the patient mobilized within 6 hours and was discharged the next day. This case highlights the feasibility and safety of TPVB-based NIVATS in a high-risk patient, aligning with ERAS goals of enabling early recovery, avoiding airway instrumentation and minimizing opioid use.

The implementation of enhanced recovery after surgery (ERAS) protocols has led to increased interest in nonintubated video-assisted thoracoscopic surgery (NIVATS), especially in patients with compromised pulmonary function. We present a case of a 62-year-old female with stage IIIA breast cancer and pulmonary bronchiectasis who underwent right-sided wedge resection via NIVATS. A two-level thoracic paravertebral block (TPVB) at T4 and T6 using 0.4% isobaric bupivacaine with epinephrine was performed, resulting in sensory block from T2 to T7. An intrathoracic vagal block with 0.5% bupivacaine was administered to prevent cough. Sedation was maintained with dexmedetomidine and remifentanil. Surgery lasted 83 minutes with no complications. Postoperatively, pain was minimal (NRS 0–2), the patient mobilized within 6 hours and was discharged the next day. This case highlights the feasibility and safety of TPVB-based NIVATS in a high-risk patient, aligning with ERAS goals of enabling early recovery, avoiding airway instrumentation and minimizing opioid use.

The implementation of enhanced recovery after surgery (ERAS) protocols has led to increased interest in nonintubated video-assisted thoracoscopic surgery (NIVATS), especially in patients with compromised pulmonary function. We present a case of a 62-year-old female with stage IIIA breast cancer and pulmonary bronchiectasis who underwent right-sided wedge resection via NIVATS. A two-level thoracic paravertebral block (TPVB) at T4 and T6 using 0.4% isobaric bupivacaine with epinephrine was performed, resulting in sensory block from T2 to T7. An intrathoracic vagal block with 0.5% bupivacaine was administered to prevent cough. Sedation was maintained with dexmedetomidine and remifentanil. Surgery lasted 83 minutes with no complications. Postoperatively, pain was minimal (NRS 0–2), the patient mobilized within 6 hours and was discharged the next day. This case highlights the feasibility and safety of TPVB-based NIVATS in a high-risk patient, aligning with ERAS goals of enabling early recovery, avoiding airway instrumentation and minimizing opioid use.

Background and Objective: Hip fractures among the elderly continue to be a serious public health concern. Hip fractures result in extremely painful injuries and given the higher risk of the elderly for complications, managing pain in this population can be challenging. This study aimed to describe the outcomes of peripheral nerve blocks on elderly patients with fragility hip fractures who will undergo elective or emergency hip surgery. Methods: A single-center prospective cohort study was conducted at the Philippine General Hospital from May 2022 to November 2022. Patients included were aged 60 years old and above with fragility hip fracture, for elective or emergency hip surgery, and with American Society of Anesthesiologists (ASA) Physical Status Score 1–3. Patients’ baseline profile, intraoperative characteristics, and postoperative outcomes were collected using a standard data collection form. The data collector was blinded to the type of block performed. Results: A total of 29 patients who underwent hip surgery were included in the study. Most (65.5%) had Subarachnoid block + Peripheral Nerve Block (SAB+PNB) while 24.1% had General Anesthesia + Peripheral Nerve Block (GA+PNB) and 10.3% had no Peripheral Nerve Block (PNB). The median Numerical Rating Scale (NRS) 30 minutes post block was similar (p=0.977) in those who had PNB blocks (GA+PNB = 0, SAB+PNB = 0). The median NRS at rest during Postoperative day 1 (POD1) was significantly highest (p=0.023) in the No PNB group (3) than in both GA+PNB (0) and SAB+PNB (0). In contrast, the median NRS at rest during POD2 was similar (p=0.713) in the three groups (GA+PNB = 0, SAB+PNB = 0, No PNB = 0). The median NRS at motion during POD1 was significantly highest (p=0.008) in the No PNB group (6) than in both GA+PNB (0) and SAB+PNB (1). Also, the median NRS at motion during POD2 was significantly highest (p=0.009) in No PNB group (4) than in both GA+PNB (0) and SAB+PNB (1). Median Morphine Milligram Equivalent (MME) of postoperative opioid was significantly higher in the No PNB group among the three groups (p=0.047). The median satisfaction score (p=0.210), median delirium score at POD2 (p=0.993), and median length of hospitalization (p=0.173) were all similar in the three groups. Conclusion Peripheral nerve block is effective in elderly patients undergoing surgery for fragility hip fractures. It results in lower pain scores and can be administered with equal effectiveness either with general anesthesia or with subarachnoid block. Mortality rate, incidence of delirium, and hospital length of stay did not vary between those with and without peripheral nerve block.
regional anesthesia ; anesthesia, conduction

Background and Objective: Hip fractures among the elderly continue to be a serious public health concern. Hip fractures result in extremely painful injuries and given the higher risk of the elderly for complications, managing pain in this population can be challenging. This study aimed to describe the outcomes of peripheral nerve blocks on elderly patients with fragility hip fractures who will undergo elective or emergency hip surgery. Methods: A single-center prospective cohort study was conducted at the Philippine General Hospital from May 2022 to November 2022. Patients included were aged 60 years old and above with fragility hip fracture, for elective or emergency hip surgery, and with American Society of Anesthesiologists (ASA) Physical Status Score 1–3. Patients’ baseline profile, intraoperative characteristics, and postoperative outcomes were collected using a standard data collection form. The data collector was blinded to the type of block performed. Results: A total of 29 patients who underwent hip surgery were included in the study. Most (65.5%) had Subarachnoid block + Peripheral Nerve Block (SAB+PNB) while 24.1% had General Anesthesia + Peripheral Nerve Block (GA+PNB) and 10.3% had no Peripheral Nerve Block (PNB). The median Numerical Rating Scale (NRS) 30 minutes post block was similar (p=0.977) in those who had PNB blocks (GA+PNB = 0, SAB+PNB = 0). The median NRS at rest during Postoperative day 1 (POD1) was significantly highest (p=0.023) in the No PNB group (3) than in both GA+PNB (0) and SAB+PNB (0). In contrast, the median NRS at rest during POD2 was similar (p=0.713) in the three groups (GA+PNB = 0, SAB+PNB = 0, No PNB = 0). The median NRS at motion during POD1 was significantly highest (p=0.008) in the No PNB group (6) than in both GA+PNB (0) and SAB+PNB (1). Also, the median NRS at motion during POD2 was significantly highest (p=0.009) in No PNB group (4) than in both GA+PNB (0) and SAB+PNB (1). Median Morphine Milligram Equivalent (MME) of postoperative opioid was significantly higher in the No PNB group among the three groups (p=0.047). The median satisfaction score (p=0.210), median delirium score at POD2 (p=0.993), and median length of hospitalization (p=0.173) were all similar in the three groups. Conclusion Peripheral nerve block is effective in elderly patients undergoing surgery for fragility hip fractures. It results in lower pain scores and can be administered with equal effectiveness either with general anesthesia or with subarachnoid block. Mortality rate, incidence of delirium, and hospital length of stay did not vary between those with and without peripheral nerve block.
regional anesthesia ; anesthesia, conduction

Background: Serratus anterior plane block (SPB) is a relatively new regional anesthetic technique that provides long-lasting anesthesia, extended postoperative analgesia, and demonstrates less consumption of opioid analgesic compared to local infiltration anesthesia (LIA). Objective: To compare the outcomes of SPB and LIA as anesthetic techniques among patients undergoing chest tube thoracostomy (CTT) insertion. Design: Cohort study. Setting: Department of Surgery, Southern Philippines Medical Center, from October 2017 to May 2019. Participants: 110 male and female patients aged >18 years old undergoing CTT given either SPB or LIA. Main outcome measures: Mean VAS during the procedure, at PACU, and 4, 8, 12, 16, 18, and 24 hours postoperatively. Main results: Of the 110 patients undergoing CTT in this study, 55 (50%) where under SPB, and the remaining 50% where under LIA. Compared to those under LIA, patients under the SPB group had significantly lower mean VAS during the procedure (4.02 ± 1.43 vs 2.76 ± 1.35; p<0.0001), and at post-anesthesia care unit (4.25 ± 1.87 vs 3.15 ± 1.56; p=0.0010). The mean level of physician's satisfaction on the procedure was significantly higher in the SPB group than in the LIA group (3.56 ± 0.50 vs 2.96 ± 0.33; p<0.0001). The mean dose of fentanyl as supplemental anesthetic agent was significantly higher in the LIA group than those in the SPB group (1.38 ± 0.59 vs 0.95 ± 0.29; p<0.0001). Similarly, the mean dose of nalbuphine, as rescue opioid dose, was significantly higher in the LIA group than in the SPB group (2.16 ± 0.57 vs 1.53 ± 0.57; p<0.0001). Conclusion Patients under SPB who underwent CTT had less pain during the procedure and at the PACU, and used lower doses of the supplemental anesthetic agent (fentanyl) during the procedure, and of the rescue opioid analgesic (nalbuphine), postoperatively.
Anesthesia, Conduction

BACKGROUND: Whether regional anesthesia may help to prevent disease recurrence in cancer patients is still controversial. The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is one of the most important sources of heterogeneity for the treatment effect. We sought to update existing systematic reviews and clarify the effect of regional anesthesia on cancer recurrence in late-stage cancer patients. METHODS: Medline, Embase, and Cochrane Library were searched from inception to September 2020 to identify randomized controlled trials (RCTs) and cohort studies that assessed the effect of regional anesthesia on cancer recurrence and overall survival (OS) compared with general anesthesia. Late-stage cancer patients were primarily assessed according to the American Joint Committee on Cancer Cancer Staging Manual (eighth edition), and the combined hazard ratio (HR) from random-effects models was used to evaluate the effect of regional anesthesia. RESULTS: A total of three RCTs and 34 cohort studies (including 64,691 patients) were identified through the literature search for inclusion in the analysis. The risk of bias was low in the RCTs and was moderate in the observational studies. The pooled HR for recurrence-free survival (RFS) or OS did not favor regional anesthesia when data from RCTs in patients with late-stage cancer were combined (RFS, HR = 1.12, 95% confidence interval [CI]: 0.58-2.18, P = 0.729, I2 = 76%; OS, HR = 0.86, 95% CI: 0.63-1.18, P = 0.345, I2 = 48%). Findings from observational studies showed that regional anesthesia may help to prevent disease recurrence (HR = 0.87, 95% CI: 0.78-0.96, P = 0.008, I2 = 71%) and improve OS (HR = 0.88, 95% CI: 0.79-0.98, P = 0.022, I2 = 79%). CONCLUSIONS RCTs reveal that OS and RFS were similar between regional and general anesthesia in late-stage cancers. The selection of anesthetic methods should still be based on clinical evaluation, and changes to current practice need more support from large, well-powered, and well-designed studies.
Anesthesia, Conduction ; Humans ; Neoplasms ; Recurrence

Anesthesia, Conduction ; Nerve Block ; Ultrasonography ; Ultrasonography, Interventional

Proficiency in ultrasound-guided regional anesthesia (UGRA) requires the practitioner to acquire cognitive and technical skills. For anesthesiology residents, an assortment of challenges has been identified in learning UGRA skills. Currently, a validated UGRA curriculum for residents does not exist, and the level of UGRA proficiency achieved during residency training can vary considerably. Simulated practice has been shown to enhance proficiency in UGRA, and a competency-based education with simulation training has been endorsed for anesthesiology residents. The objective of this review is to outline simulation-based training that can be implemented in a UGRA curriculum and to explore educational tools like gamification to facilitate competency in regional anesthesiology.
Anesthesia, Conduction ; Anesthesiology ; Competency-Based Education ; Curriculum ; Internship and Residency ; Learning ; Nerve Block ; Simulation Training ; Ultrasonography

BACKGROUND: The breast is innervated by the intercostal nerves and the brachial plexus. We propose a technique to perform breast surgery without general anesthesia using the erector spinae plane (ESP) block and selective block of four nerves that arise from the brachial plexus innervate the breast and the axilla (SBP block). CASE: A 77-year-old man with breast cancer was scheduled for radical mastectomy and axillary clearance. He had a previous history of myocardial infarction with dilated cardiomyopathy and severely impaired ejection fraction. The surgery was performed under regional anesthesia with combined ESP and SBP block. The patient did not require opioids or other supplemental analgesics intra- or postoperatively and was discharged uneventfully. CONCLUSIONS: SBP is a novel block that selectively blocks branches of the brachial plexus that innervate the breast.
Aged ; Analgesics ; Analgesics, Opioid ; Anesthesia, Conduction ; Anesthesia, General ; Axilla ; Brachial Plexus Block ; Brachial Plexus ; Breast Neoplasms ; Breast ; Cardiomyopathy, Dilated ; Humans ; Intercostal Nerves ; Mastectomy, Radical ; Myocardial Infarction