Bangladesh Journal of Pain

Recent Advances and Future Directions in Perioperative and Chronic Pain Management – A Perspective from Bangladesh

2025-07-30T00:12:41+00:00

Recent advancements in perioperative pain management have been transformative, particularly the application of ultrasound-guided (USG) regional anesthesia techniques and multimodal analgesia. Ultrasound-guided regional anesthesia allows for real-time visualization of nerves, muscles, and vascular structures, enabling precise needle placement and local anesthetic delivery. This precision significantly enhances block success rates and reduces the risk of complications such as inadvertent nerve injury, vascular puncture, and local anesthetic systemic toxicity (LAST). For example, USG-guided nerve blocks like erector spinae plane block, brachial plexus block, IPACK, and genicular nerve blocks have substantially improved perioperative outcomes by providing superior analgesia, reduced opioid requirements, and faster mobilization, thereby shortening hospital stays and accelerating recovery.

Effects of Preemptive Analgesia by Caudal Route using Spinal Column Height Based Formula for Dose Calculation in Paediatric Patients Undergoing Infra Umbilical Surgery

2025-07-31T16:01:50+00:00

Background: Caudal analgesia is a widely used technique for providing perioperative pain relief in pediatric patients undergoing infraumbilical surgeries. However, determining the appropriate dosage of local anesthetic agents can be challenging due to variations in pediatric anatomy and body habitus. Various formulae have been used for dose calculation based on body weight, spinal column height, age of patient, rate of injection etc. It is not possible to address all these factors while constructing these formulae. This study aims to explore that use of spinal column height-based formulae for dose calculation aiming to optimize analgesia while minimizing the risk of adverse effects other than body weight-based formulae.
Methods: This Quasi experimental study was carried out between June 2022 to November 2023 at Dhaka Medical College and Hospital. 50 patients belonging to ASA I and II of either sexes (25 patients in each group) were randomly allocated into two groups equally; Group A (Study group) received 0.25% plain bupivacaine according to spinal column height based modified Spiegel formulae and Group B (Control group) received 0.25% plain bupivacaine according to body weight based Armitage formulae. Drug volume was calculated according to respective formulae in both groups. Respiratory rate, Oxygen saturation and haemodynamic parameters (HR, MAP) were recorded at different time level. In the Post Anaesthesia Care Unit (PACU), level of sensory block and pain intensity were assessed by pin prick method and Wong Baker FACES pain scores respectively, at 5, 10, 15, 20, 30, 60 and 120 minutes then hourly upto 6 hours. Level of motor block was also assessed by modified Bromage scale during this period.
Results: The mean number of spinal segments blocked was significantly different among groups (p< 0.001) with patients in group A (4.11±0.22) showing significantly lower number of spinal segments blocked as compared to that in group B (4.40±0.21; p< 0.001). The mean volume of 0.25% bupivacaine used in group A was significantly lower (p< 0.001) than that in group B.
Conclusion: Caudal analgesia utilizing a spinal column height-based formula for dose calculation offers a reliable and precise approach for pain management in pediatric patients undergoing infraumbilical surgery while minimizing the risk of adverse events.

Role of Levobupivacaine and Fentanyl in Second Stage of Labour: An Observational Study

2025-07-31T16:24:05+00:00

Background: To achieve adequate analgesia with a possible non-significant motor block, the American Society of Anaesthesiologists (ASA) recommended using a minimal concentration of local anaesthetics for labour epidurals. However, the concentration of local anaesthetics needs to increase to achieve effective analgesia in the second stage, as more recruitment of A-δ fibre occurs. This study compared the effects of the epidural bolus of Levobupivacaine-Fentanyl and Bupivacaine- Fentanyl in the second stage of labour.
Methods: This study was carried out from April 2023 to March 2024 at the labour suit of the Department of Obstetrics and Gynaecology of Bangladesh Medical University (BMU) and Mohammadpur Fertility Services and Training Centre (MFSTC), Dhaka, under the supervision of the Department of Anaesthesia, Analgesia, and Intensive Care Medicine, BMU. Parturient requesting
labour analgesia, satisfying the inclusion criteria were randomly divided equally into Groups LF (Levobupivacaine and Fentanyl) and BF (Bupivacaine and Fentanyl). Epidural was performed at the first stage of labour (cervical dilatation ≥4 cm) and an epidural dose of 6 ml of 0.1% levobupivacaine with fentanyl 2μg/ml through the epidural catheter was administered. Degree of analgesia by VAS, motor block by Bromage scale, foetal heart rate, and blood pressure were assessed at 5, 15, and 30 minutes after epidural dosage and then hourly till delivery. At the late second stage of labour, an epidural bolus dose of 12 ml of 0.1% Bupivacaine-Fentanyl solution in group BF and 12 ml of 0.1% Levobupivacaine-Fentanyl solution in group LF was administered. After bolus, the duration of the second stage of labour, mode of delivery, and maternal satisfaction by Likert scale were measured.
Results: The study involved 44 participants who were statistically matched for age, BMI and gestational age. Pain intensity was measured by the Visual Analogue Scale (VAS), the baseline VAS scores before the bolus had a slightly lower score in the BF group (P = 0.426) and after the bolus administration, the LF group showed a significantly lower VAS score than the BF group (P = 0.001). The LF group had a notably shorter second stage (22.75±9.97) compared to the BF group (52.67±17.19) (p<0.05). Maternal satisfaction favoured LF and superior analgesic effectiveness (p<0.005).
Conclusion: The study demonstrates that epidural administration of levobupivacaine-fentanyl in the second stage achieved better analgesia, significantly shorter duration, and remarkable maternal satisfaction in comparison to bupivacaine-fentanyl.

Effectiveness of Dexamethasone versus Clonidine as an Adjuvant to Bupivacaine for Ultrasound-guided Supraclavicular Brachial Plexus Block in Patients Undergoing Upper Limb Surgery

2025-07-31T16:47:00+00:00

Background: Supraclavicular Brachial Plexus Block has become one of the most important anaesthetic techniques for surgeries in the upper limb. In modern anaesthesia practices, various pharmacological agents are used as an adjuvant to provide faster onset and longer duration of analgesia of local anaesthetic agent after single injection peripheral nerve blocks. This study was designed for the evaluation of the effectiveness of dexamethasone versus clonidine as an adjuvant to bupivacaine for Ultrasound-guided Supraclavicular Brachial Plexus Block in patients undergoing upper limb surgery.
Methods: This randomized controlled trial was carried out from September 2021 to August 2022 at Dhaka Medical College and Hospital. Patients were included according to inclusion and exclusion criteria. A total of 75 patients were enrolled in the study. Patient’s allocation into three groups were done by computer generation random numbers: Group A- received 18 ml of 0.5% Bupivacaine (plain) and 2 ml of normal saline. Group B- received 18 ml of 0.5% Bupivacaine (plain) with 2ml (10mg) of Dexamethasone, and Group C- received 18 ml of 0.5% Bupivacaine (plain) and 2 ml (100μg) of Clonidine. The required time for onset and duration of sensory and motor block, time for first demand of analgesia and total consumptions of analgesics within 24hours, haemodynamic parameters, and adverse effects were observed among three groups.
Result: The demographic profiles were similar between three groups (p > 0.05). Considering the time for complete sensory block (23.6±3.1 vs 18.9±3.2 vs 14.7±3.0) & time for the onset of maximum motor level (29.5±3.9 vs 23.5±3.1 vs 20.8±2.4), significantly less in clonidine (group C) than that of normal saline (group A) & dexamethasone (group B) group (p < 0.05). The Ramsey sedation score was high in group C in first eight hours during postoperative periods than two others groups which was also statistically significant (p < 0.05). The time to regression of sensory block (242.1±16.57 vs 932.9±44.9 vs 739.16 ±13.47) & motor block (175.6±17.5 vs 780.8±26.2 vs 570.6 ±22.0) was significantly longer in group B than that of other two group which was statistically significant (p <0 .05). Similarly in comparison to other two groups, group B had significantly increased (190.8±18.3 vs 810.6±25.8 vs 600.6±24.9) (p < 0.05) in respect of time for motor recovery. On the other hand, group B had significantly increased result in aspect of time for Ist demand of analgesic (260.6±23.0 vs 975.2±29.0 vs 760.8±25.5), significantly decreased total analgesic requirements in 24 hours (232.8±15.5 vs 84.7±13.8 & 166.1±19.4) & also significantly decreased total anti-emetic requirement in 24 hours (11.8±0.3 vs 4.1±0.8 & 8.0±0.0) (p < 0.05) which was statically significant than that of others two groups. All adverse effects were significantly less in group B than in groups A & group C. (p < 0.05).
Conclusion: Dexamethasone is more effective than clonidine as an adjuvant to bupivacaine for Ultrasound-guided Supraclavicular Brachial Plexus block.

Efficacy of Platelet-Rich Plasma Therapy in Athletes Returning to Sport: A Randomized Controlled Trial

2025-07-31T17:14:52+00:00

Background: Platelet-rich plasma (PRP) therapy has garnered increasing attention in sports medicine due to its proposed ability to accelerate tissue healing and reduce downtime following musculoskeletal injuries. In athletes, rapid return to pre-injury performance is paramount, yet evidence regarding the efficacy of PRP in facilitating earlier and safer return to sport remains inconclusive. The objective of this study was to assess the efficacy of platelet-rich plasma in athletes returning to sport.
Methods: This prospective, randomized controlled trial was conducted at a single sports medicine facility in India. Athletes with acute or subacute sports-related tendon injuries were enrolled and randomized into two groups. One group (PRP) received ultrasound-guided PRP injection, and another group (Control) received saline as a placebo injection, followed by a standardized rehabilitation protocol. The primary outcome measure was time to return to full sports participation, and secondary outcomes included pain intensity using Visual Analog Scale (VAS) and function using Cincinnati Sports Activity Scale assessed at baseline, 4 weeks, and 12 weeks. Safety and adverse events were also documented.
Results: A total of 60 participants were included in this study. Athletes who received PRP demonstrated a significantly shorter mean time to return to sport (5.9 ± 1.2 weeks) compared to controls (7.4 ± 1.6 weeks; p<0.01). Moreover, the PRP group exhibited marked improvements in VAS pain scores and functional ratings at both 4 and 12 weeks (p < 0.05). No severe adverse events were recorded; mild, transient post-injection pain was the most frequently reported side effect in both groups.
Conclusion: Our findings suggest that PRP therapy can be a viable adjunct in the management of sports-related tendon injuries, potentially expediting return-to-play timelines and improving pain and function in the short to mid-term. Further large-scale, multicenter trials are warranted to confirm these results and optimize PRP preparation and delivery methods.

Ultrasound Guided Erector Spinae Plane Block and Quadratus Lumborum Block for Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomy: A Comparative Study

2025-07-31T17:33:43+00:00

Background: Quadratus lumborum block is a peripheral block method that has been used successfully for pain relief after total abdominal hysterectomy. Prolonged analgesia has been reported as compared with more conventional transversus abdominis plane (TAP) block. Erector spinae plane (ESP) block is a novel interfascial plane block used in postoperative pain and chronic neuropathic pain relief of the thoracoabdominal region. Recently it has been used as a postoperative regional analgesia technique in different surgeries from the shoulder to hip regions due to its simplicity and efficacy. This study was designed to compare the efficacy of ultrasound guided erector spinae plane block and quadratus lumborum block for postoperative analgesia in patients undergoing total abdominal hysterectomy.
Methods: This randomized prospective double-blinded comparative study was carried out form July 2021 to June 2022 at Dhaka Medical College. A total of 60 patients were enrolled in this study and randomized into two groups (ESPB and QLB-2). 1st group (Group: ESPB): received bilateral ultrasound-guided Erector Spinae Plane (ESPB) block with each block 20ml of 0.25% bupivacaine at the level of T9, 2nd group (Group: QLB-2): received bilateral ultrasound-guided posterior Quadratus Lumbroum block (QLB-2) with the same volume and concentration of bupivacaine. Following parameters were observed, recorded and compared between two groups: postoperative pain intensity using VAS score, the total amount of opioid consumption in the first 24 hours after the operation, the time of first rescue analgesia and possible adverse events such as hypotension, nausea/vomiting, shivering, dizziness, itching etc. during the postoperative period.
Results: There were no significant differences found according to demographic and clinical status between two groups. The failed block rate was high in group B which was 13.3% (p = 0.011). At 16th and 24th hour mean heart rate (HR), SBP & MAP were significantly higher in group B (p < 0.05) than group A. In Group A mean HR, SBP & MAP were higher at 20th hour than group B and statistically significant differences (p < 0.05) observed. After assessing VAS score during postoperative period, it was observed that VAS score was significantly higher in group B, at 16th and 24th hour (p < 0.05) than group A. In group A, VAS score was higher than group B at 20th hour and found statistically significant (p < 0.05). Time of first rescue analgesia (hrs) for ESP group and QLB group were 20±1.4 hours & 16.7±1.2 hours respectively and the difference was statistically significant (p < 0.05). Total opioid (pethidine) requirement in 1st 24 hours (mg) was significantly higher (136.8±9.4 mg) in QLB group than ESP group (79.6±8.6 mg) as p < 0.05. Incidence of adverse events like nausea (23.08%), vomiting (15.4%) and itching (19.2%) were higher in group B then group A which were also statistically significant (p < 0.05).
Conclusion: After total abdominal hysterectomy under SAB, ESP block provide longer duration of analgesia, low VAS score during postoperative period with less requirement of opioid in 1st 24 hours as well as lower postoperative complications when compared to QL block-2.

Ultrasound-Guided Platelet-Rich Plasma Injection for the Treatment of Triangular Fibrocartilage Complex Injury: A Case Report on Efficacy and Outcomes

2025-07-31T17:48:11+00:00

Triangular fibrocartilage complex (TFCC) injuries are a common yet frequently overlooked cause of chronic wrist pain, particularly post-trauma. Non-surgical treatment options remain limited, but platelet-rich plasma (PRP) therapy has emerged as a promising alternative. This case report describes a 32-year-old male with chronic right wrist pain following a motorcycle accident. MRI confirmed a Type 1C TFCC injury. He received two sessions of ultrasound-guided PRP injections, which resulted in significant improvement in pain and function, as assessed by Patient-Rated Wrist Evaluation (PRWE) score. This case highlights the potential of PRP therapy as a safe, effective, and minimally invasive option for managing TFCC injuries.